Updated 26 August 2022
We carried out this announced focused inspection on 16 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 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 were in place, but emergency equipment required review.
- The staff awareness of sepsis and the logging of prescriptions could be improved.
- The provider had systems to help them manage risk to patients and staff, but an effective system was needed to monitor and dispose of out of date stock.
- 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.
- 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 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 had information governance arrangements.
Background
Mount Dental Practice is in Batley and provides dental care and treatment for adults and children.
There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice.
The dental team includes three dentists, six dental nurses, practice manager and two receptionists. The practice has three treatment rooms.
During the inspection we spoke with two dentists and the compliance manager and practice manager. 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 5.30pm
Friday 9am to 2pm
There were areas where the provider could make improvements. They should:
- Review the system of checks of medical emergency equipment taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.
- Implement an effective system for identifying, disposing and replenishing of out-of-date stock.
- Improve the process for tracking and monitoring the use of NHS prescription pads in the practice.
- Take action to implement any recommendations in the practice's Legionella risk assessment, 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.’ In particular recording actual water temperatures and ensuring key staff have training in Legionella awareness and management.