Updated 1 April 2022
We carried out this announced focused inspection on 16 March 2022 under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered practice was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a Care Quality Commission, (CQC), inspector who was supported by a specialist dental adviser.
To get to the heart of patients’ experiences of care and treatment, we usually ask five key questions, however due to the ongoing COVID-19 pandemic and to reduce time spent on site, only the following three questions were asked:
• Is it safe?
• Is it effective?
• Is it well-led?
These questions form the framework for the areas we look at during the inspection.
Our findings were:
- The dental clinic appeared to be visibly clean and well-maintained.
- The practice had infection control procedures which mostly reflected published guidance.
- Staff knew how to deal with medical emergencies. Appropriate emergency medicines and most life-saving equipment were available. Missing face masks and out of date equipment including, the oxygen cylinder, and adult and paediatric self-inflating bags, were ordered immediately after the inspection.
- The practice had some systems to help them manage risk to patients and staff. We found shortfalls in appropriately assessing and mitigating risks in relation to infection control equipment maintenance and the management of substances hazardous to health.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The practice had staff recruitment procedures which reflected current legislation.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Patients were treated with dignity and respect and staff took care to protect their privacy and personal information.
- Staff provided preventive care and supported patients to ensure better oral health.
- There was effective leadership and a culture of continuous improvement. However, we found that radiography and infection prevention and control audits were completed annually. National guidance states these should be completed six monthly.
- Staff felt involved and supported and worked as a team.
- Staff and patients were asked for feedback about the services provided.
- The dental clinic had information governance arrangements.
Background
The provider has one practice and this report is about Beech Hill Dental Practice.
Beech Hill Dental Practice is in Luton and provides NHS and private dental care and treatment for adults and children.
There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces are available in a car park to the rear of the practice. The practice has made some adjustments to support patients with additional needs.
The dental team includes two dentists, and three dental nurses who also work on reception. The practice has two treatment rooms.
During the inspection we spoke with two dentists, and two dental nurses. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Mondays to Thursdays from 9am to 5pm
Fridays from 9am to 3pm
Saturdays from 8am to 1pm
The practice is a well-established practice with staff who have worked there for a long time.
There were areas where the provider could make improvements. They should
- Take action to ensure the availability of equipment in the practice to manage medical emergencies and implement an effective system of identifying, disposing and replenishing of out-of-date medical equipment and medicines taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.
- Take action to ensure audits of radiography and infection prevention and control are undertaken six-monthly to improve the quality of the service. The practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.
- Improve the practice's systems for checking and monitoring equipment taking into account relevant guidance and ensure that all equipment is well maintained. In particular, the ultrasonic device and autoclave used as a backup in the practice.
- Improve the practice's processes for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken for all cleaning products.