Updated 12 March 2018
We carried out this announced inspection on 23 January 2018 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 providing well-led care in accordance with the relevant regulations.
Background
Complete Dental - Bearwood is in Smethwick and provides NHS and private treatment to patients of all ages.
There is level access for people who use wheelchairs and pushchairs. Car parking spaces are available at the front of the practice but are time limited, other parking is available near the practice in a pay and display car park or local side roads.
The dental team consists of eight dentists (including the principal dentist), six dental nurses (including the assistant manager), one dental hygienist, one receptionist and the practice manager. There are has six treatment rooms, three on the ground floor and three on the first floor of the practice.
The practice is owned by a company and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run. The registered manager at Complete Dental Bearwood is the principal dentist.
On the day of inspection we received feedback from 32 patients and this information gave us a positive view of the practice.
During the inspection we spoke with two dentists, two dental nurses, the dental hygienist, the receptionist, the assistant manager and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open: Monday to Friday 8.45am to 5.30pm. The practice does not close at lunchtime.
Our key findings were:
- The practice was clean and well maintained.
- The practice had infection control procedures which reflected published guidance. Issues were identified during the decontamination process which were discussed with staff at the time. Following this inspection the practice manager forwarded information to staff regarding hand washing during the decontamination process.
- Staff knew how to deal with emergencies. Some items of life-saving equipment were missing but these were ordered during the inspection.
- The practice had systems to help them manage risk.
- The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
- The practice had thorough staff recruitment procedures.
- The clinical staff provided patients’ care and treatment in line with current guidelines although basic periodontal examination scores were not recorded on patient records on each occasion.
- Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
- The appointment system met patients’ needs.
- The practice had effective leadership. Staff felt involved and supported and worked well as a team.
- The practice asked patients for feedback about the services they provided.
- The practice dealt with complaints positively and efficiently.
There were areas where the provider could make improvements. They should:
- Review the practice’s system for documentation of actions taken, and learning shared, in response to accidents and incidents with a view to preventing further occurrences and ensuring that improvements are made as a result.
- Review the current staffing arrangements to ensure all dental care professionals are adequately supported by a trained member of the dental team when treating patients in a dental setting taking into account the guidance issued by the General Dental Council.
- Review the practice's protocols for completion of dental care records taking into account guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.
- Review the practice’s responsibilities to the needs of people with a disability, including those with hearing difficulties and the requirements of the Equality Act 2010.