Pelham Dental Studio

We carried out this announced inspection on 18 July 2019 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 CQC inspector who was supported by a specialist dental adviser.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five 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:

Are services safe?

We found that this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this practice was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this practice was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this practice was not providing well-led care in accordance with the relevant regulations.

Background

Pelham Dental Studio is in Gravesend and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces, including some for blue badge holders, are available on the practice premises.

The dental team includes one dentist, one dental nurse, and two receptionists. The practice has one treatment room.

The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.

On the day of inspection, we collected 34 CQC comment cards filled in by patients and spoke with five other patients.

During the inspection we spoke with one dentist, one dental nurse and one receptionist. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Thursday 9am to 5pm

Friday 9am to 12pm

Our key findings were:

• The practice appeared clean and well maintained.
• The provider had infection control procedures which reflected published guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and most life-saving equipment were available.
• The provider had some systems to help them manage risk to patients and staff, however these could be improved.
• The provider did not have a safeguarding process. Staff, when questioned knew some of their responsibilities for safeguarding vulnerable adults and children. However, not all staff had completed safeguarding training.
• The provider did not have thorough staff recruitment procedures.
• 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 supporting patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• The provider did not have effective leadership or a culture of continuous improvement.
• Staff felt involved and supported and worked well 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 did not have suitable information governance arrangements.

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 recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
• Ensure patients are protected from abuse and improper treatment

Full details of the regulation/s the provider was/is not meeting are at the end of this report.