Updated 4 April 2023
We carried out this announced comprehensive inspection on 10 February 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 practice had infection control procedures which reflected published guidance.
- Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
- The practice had systems to manage risks for patients, staff, equipment and the premises.
- We found shortfalls in assessing and mitigating risks in relation to substances hazardous to health, premises and medicines management.
- The practice carried out dental care treatment under conscious sedation, however, they did not have the reversal medicine on site.
- 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.
- Clinical staff provided patients’ care and treatment in line with current guidelines, however, patient care records lacked detail.
- 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’s arrangements for ensuring good governance needed improving to ensure sustainability in the long term.
- Staff felt involved, supported and worked as a team.
Background
This report is about St Mary’s Dental Care.
St Mary’s Dental Care is in Upminster in the London Borough of Havering 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 practice has made reasonable adjustments to support patients with access requirements. The practice is situated close to public transport bus and rail services.
The dental team includes 2 dentists, 1 visiting sedationist, 1 qualified dental nurse, 1 trainee dental nurse, 1 dental hygienist and 2 receptionists. The practice has 2 treatment rooms.
During the inspection we spoke with 1 dentist, the trainee dental nurse and 1 receptionist. We looked at practice policies, procedures and other records to assess how the service is managed.
The practice is open:
Monday to Thursday 9am – 6pm
Friday 9am – 7pm
Saturday 9am – 6pm.
We identified regulations the provider was not complying with. They must:
- Ensure care and treatment is provided in a safe way to patients.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
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:
- Implement an effective system for monitoring and recording the fridge temperature to ensure that medicines and dental care products are being stored in line with the manufacturer’s guidance.
- Implement an effective system for receiving and responding to patient safety alerts, recalls and rapid response reports issued by the Medicines and Healthcare products Regulatory Agency, the Central Alerting System and other relevant bodies, such as Public Health England.
- Take action to ensure the clinicians take into account the guidance provided by the College of General Dentistry when completing dental care records.
- Implement audits for prescribing of antibiotic medicines taking into account the guidance provided by the College of General Dentistry.