Updated 19 August 2022
We carried out this announced focused inspection on 9 August 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 medicines and life-saving equipment were available.
- The practice had systems to help them manage risk to patients and staff with the exception of minor shortfalls found in Control of Substances Hazardous to Health (COSHH) management.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The practice had a staff recruitment policy which reflected current legislation although the practice did not always follow this. In particular, in obtaining evidence of satisfactory conduct in previous employment (references) for all staff.
- 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. However, improvements were identified to ensure audits were completed at the recommended frequency.
- 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 two practices and this report is about Borehamwood Dental Practice.
Borehamwood Dental Practice is in Borehamwood, Hertfordshire and provides NHS and private dental care and treatment for adults and children.
The dental practice is on the first floor and is accessed by a set of stairs, so it is not accessible to wheelchair users. The provider signposts patients with such needs to practices nearby. There is car parking available in a pay and display carpark near the practice.
The practice has made some adjustments to support patients with additional needs.
The dental team includes five dentists, three dental nurses including one trainee dental nurse, one receptionist and a practice manager. A compliance advisor provides the practice with governance support. The practice has two treatment rooms.
During the inspection we spoke with one dentist, one dental nurse, one receptionist, the practice manager and the compliance advisor. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday to Friday from 8.30am to 5.30pm
There were areas where the provider could make improvements. They should:
- Improve the practice's recruitment procedures to ensure accurate, complete and detailed records are maintained for all staff and that appropriate checks are completed prior to new staff commencing employment at the practice. In particular, ensuring satisfactory evidence of conduct in previous employment (references) is sought for all staff in line with the practice’s recruitment policy.
- Take action to ensure audits of infection prevention and control, and radiography are undertaken at recommended intervals 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 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 general cleaning products used at the practice.