Archived: D Beardmore Dental Surgery

Updated 30 June 2016

We carried out an announced, comprehensive inspection on 15 December 2015. The inspection took place over one day and was carried out by a lead inspector and a dental specialist adviser.

During our inspection visit, we reviewed policy documents and staff records. We spoke with both of the members of staff. We conducted a tour of the practice and looked at the storage arrangements for emergency medicines and equipment. We were shown the decontamination procedures for dental instruments. We received feedback from 27 patients and all feedback received was positive. Patients were extremely satisfied with the service provided by the practice.

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 30 June 2016

Background

D Beardmore Dental Practice has one dentist (Mr Beardmore) who works part time and a qualified dental nurse who is registered with the General Dental Council (GDC). The practice’s opening hours are from 8.40am to 5.40pm on a Tuesday and from 8.40am to 12.40pm on a Wednesday.

D Beardmore Dental Practice provides private treatment for adults and children. The practice is situated in a converted residential property. The practice had one dental treatment room on the first floor; decontamination of dental equipment for cleaning, sterilising and packing dental instruments takes place in the treatment room. The reception and waiting area is in one room located next to the treatment room.

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.

Before the inspection we sent Care Quality Commission comment cards to the practice for patients to complete to tell us about their experience of the practice. We collected 24 completed cards and spoke with three patients. These provided a positive view of the services the practice provides. All of the patients commented that the quality of care was very good.

We carried out an announced comprehensive inspection on 15 December 2015 as part of our planned inspection of all dental practices. The inspection took place over one day and was carried out by a lead inspector and a dental specialist adviser.

Our key findings were:

• The practice had mechanisms in place to record significant events and accidents.
• Staff had been trained to handle medical emergencies.
• Information from completed CQC comment cards was positive and indicated a friendly, caring and professional service.
• Suitable arrangements were in place for making referrals to other dental professionals.
• Patients were treated with dignity and respect and confidentiality was maintained
• The appointment system met the needs of patients and waiting times were kept to a minimum.
• The practices radiography file did not contain all information as required in the Ionising Radiation Regulations 1999 and Ionising Radiation (Medical Exposure) Regulations 2000.
• The practice was visibly clean and well maintained. However there were some shortfalls in infection prevention and control practices.
• The practice was not always keeping an accurate, complete and contemporaneous record in respect of each patient, including a record of the decisions taken in relation to the care and treatment provided.
• Systems were not in place to assess, monitor and mitigate risks. For example there were no systems to maintain and monitor emergency equipment, first aid packs and fire systems including risk assessments. X-ray signage was not in place.
• Governance arrangements were not effective in improving the quality and safety of services.

We identified regulations that were not being met and the provider must:

• Ensure an effective system is established to assess, monitor and mitigate the various risks arising from undertaking of the regulated activities. This should include systems to maintain and monitor emergency equipment, first aid packs and fire systems including risk assessments.  Assess the risk of, and prevent, detect and control the spread of, infections, including those that are health care associated. Ensure that a Legionella risk assessment is undertaken by a competent person and any actions identified are undertaken.
• Ensure that the practice is in compliance with its legal obligations under Ionising Radiation Regulations (IRR) 99 and Ionising Radiation (Medical Exposure) Regulation (IRMER) 2000 This includes undertaking necessary action to address issues identified in the Radiation Protection Adviser’s risk assessment; and reviewing the practice’s protocols for recording in the patients’ dental care records or elsewhere the reason for taking the X-ray.

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

• 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 the practice’s arrangements for receiving and responding to patient safety alerts, recalls and rapid response reports issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and through the Central Alerting System (CAS), as well as from other relevant bodies such as, Public Health England (PHE).
• Review the practice’s procedures for fire safety. Ensuring that the fire safety policy contains information related to the practice; actions identified in the fire risk assessment have been completed and provide evidence that all fire safety equipment at the practice has been serviced as required.
• Review the practice's protocols for completion of dental records giving due regard to guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.
• Review the practice’s procedure for providing patients with accessible information on how to make a complaint and the practice’s complaints procedure.
• Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.
• Review the practice’s safeguarding policy; ensuring it covers both children and adults.
• Review the practice's recruitment procedures and develop a policy to ensure that there is a consistent approach to recruitment and selection.
• Review the practice’s audit protocols of various aspects of the service, such as radiography, consent and dental care records at regular intervals to help improve the quality of service. The practice should also check all audits have documented learning points and the resulting improvements can be demonstrated.