Archived: Ise Lodge Dental Centre

Updated 11 November 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

This inspection took place on 6 September 2016 and was led by a CQC Inspector who was supported by a specialist dental advisor. Before the inspection, we asked the practice to send us some information for review and this included a summary of complaints received.

During the inspection we spoke with two dentists, three dental nurses, the practice manager and two reception staff. We reviewed policies, procedures and other documents. We also obtained the views of four patients on the day of the inspection and received six comment cards that we had provided for patients to complete during the two weeks leading up to the inspection.

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 therefore formed the framework for the areas we looked at during the inspection.

Updated 11 November 2016

We carried out an announced comprehensive inspection on 6 September 2016 to ask the practice the following key questions; Are services safe, effective, caring, responsive and well-led?

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

Ise Lodge Dental Care is located in a quiet residential area of Kettering. The practice is in a converted, modern bungalow with access for disabled people. The practice has a waiting room where up to ten people can be seated and three treatment rooms that are accessed from the reception area.

The principal dentist is registered with the Care Quality Commission (CQC) as an individual. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is run.

As part of the inspection, we received feedback through 41 CQC comments cards completed by patients, speaking with other patients and staff during the inspection. Patients said that the staff were caring and helpful to them and they received good care and treatment.

Our key findings were:

• There was appropriate equipment for staff to undertake their duties, and equipment was well maintained.
• There were systems to promote the safe operation of the service although the reporting of incidents and significant events required development.
• The provider had emergency medicines in line with the British National Formulary (BNF) guidance for medical emergencies in dental practice although one medicine was found to be incorrectly stored and out of date.
• Patients told us they were able to get an appointment when they needed one and the staff were kind and helpful.
• Dentists provided dental care in accordance with current guidelines from the Faculty for General Dental Practice guidelines and the National Institute for Care Excellence (NICE).
• Staff had good access to training and were supported to develop their knowledge and maintain their professional development.
• Governance arrangements were in place although these required strengthening to maintain the safety of the service and promote ongoing learning and improvement.

There were areas where the provider could make improvements and should:

• Strengthen systems used to monitor quality and safety in relation to incidents, accidents, significant events, complaints and environmental risks.
• Review the process used to act on the outcomes of clinical and non clinical audits so that actions taken are clearly evidenced and can be monitored.

• Review the storage of dental care products and medicines that may require refrigeration to ensure they are stored in line with the manufacturer’s guidance and the fridge temperature is monitored and recorded.
• Review the practice’s protocols for the use of rubber dam for root canal treatment giving due regard to guidelines issued by the British Endodontic Society.
• Review staff awareness of Gillick competency and the Mental Capacity Act (2005) to ensure all staff are aware of their responsibilities.
• Review the practice’s sharps procedures in relation to the management of sharps injuries giving due regard to the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
• Review staff records so that records of Hepatitis B immunity are monitored.
• Review ongoing systems to monitor infection control practice in the treatment rooms so that all dental items are hygienically stored, supplies of materials and equipment are checked and records of cleaning completed.