Updated 10 February 2022
We carried out this announced focused inspection on 11 January 2021 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 provider 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 asked the following three questions:
- 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 practice appeared to be visibly clean and well-maintained.
- The provider had infection control procedures which reflected published guidance.
- Staff knew how to deal with emergencies.
- Appropriate medicines and life-saving equipment were mainly available.
- The provider had systems to help them manage risk to patients and staff however improvements could be made to the management of sharps and the Control of Substances Hazardous to Health file
- The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The provider had staff recruitment procedures which reflected current legislation.
- Improvements could be made to the clinician’s record in the patients’ dental care records the reason for taking X-rays, a report on the findings and the quality of the image.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
- Staff provided preventive care and supported patients to ensure better oral health.
- The appointment system took account of patients’ needs.
- The provider had effective leadership and a culture of continuous improvement.
- Staff felt involved and supported and worked as a team.
- The provider asked staff and patients for feedback about the services they provided.
- The provider dealt with complaints positively and efficiently.
- The provider had information governance arrangements.
Background
Kelsham Dental Practice – Cranleigh is in Cranleigh and provides NHS and private dental care and treatment for adults and children.
There is step free access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for disabled people, are available near the practice.
The dental team includes four dentists, two dental nurses, two trainee dental nurses and three dental hygienists. The practice has four treatment rooms.
During the inspection we spoke with two dentists, two dental nurses, two trainee dental nurses and a dental hygienist. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
- Monday 8.30am to 5pm
- Tuesday 8.30am to 5pm
- Wednesday 8.30am to 5pm
- Thursday 8.30am to 5pm
- Friday 8.30am to 4.30pm
There were areas where the provider could make improvements. They should:
- Improve the practice’s sharps procedures to ensure the practice is in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
- Take action to ensure the availability of equipment in the practice to manage medical emergencies taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.
- Take action to ensure clinicians record in the patients’ dental care records or elsewhere the reason for taking X-rays, a report on the findings and the quality of the image in compliance with Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment.
- 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 and the products are stored securely.