Updated 9 November 2023
We carried out this announced comprehensive inspection on 3 October 2023 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 advisor.
To get to the heart of patients’ experiences of care and treatment, we always ask the following 5 questions:
- Is it safe?
- Is it effective?
- Is it caring?
- Is it responsive to people’s needs?
- 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 clean and well-maintained.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- Patients were treated with dignity and respect. Staff took care to protect patients’ privacy and personal information.
- Staff provided preventive care and supported patients to ensure better oral health.
- The appointment system worked efficiently to respond to patients’ needs.
- The frequency of appointments was agreed between the dentist and the patient, giving due regard to National Institute of Health and Care Excellence (NICE) guidelines.
- The practice had information governance arrangements.
- The practice had infection control procedures which broadly reflected published guidance.
- Staff knew how to deal with medical emergencies. However, not all of the life-saving equipment and medication was available as per national guidelines.
- The practice had some systems to manage risks for patients, staff, equipment and the premises, however these were not documented effectively.
- The practice did not have staff recruitment procedures which reflected current legislation.
- The leadership, and oversight of the day-to-day management of the service needed improvements.
- Staff generally worked as a team. Improvements were needed to ensure that they were supported and involved in the delivery of care and treatment.
- Improvements were needed to ensure that clinical staff kept up to date with current guidelines, and information related to patient care was suitably recorded within the dental care records.
- There were ineffective systems to ensure that staff were up to date with their training.
- There were ineffective systems to support continuous improvement.
Background
Grove Dental Surgery is in the London Borough of Kensington and Chelsea and provides predominantly NHS 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 practice has made reasonable adjustments to support patients with access requirements.
The dental team includes the principal dentist, 7 associate dentists, 1 qualified dental nurse, 1 trainee dental nurse, 1 practice manager and 2 receptionists. The practice has 4 treatment rooms.
During the inspection we spoke with 1 dentist, the dental nurse, the trainee dental nurse, 1 receptionist and the practice manager. We also spoke with the principal dentist remotely. We looked at practice policies, procedures and other records to assess how the service is managed.
The practice is open:
Monday to Friday from 9.15 to 6pm.
We identified regulations the provider was not complying with. They must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
- Ensure specified information is available regarding each person employed.
Full details of the regulations the provider was not meeting are at the end of this report.
There were areas where the provider could make improvements. They should:
- Improve the practice’s infection control procedures and protocols taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’.
- Improve the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment.
- Implement audits for prescribing of antibiotic medicines taking into account the guidance provided by the College of General Dentistry.
- Improve the practice protocols regarding auditing patient dental care records to check that necessary information is recorded.