Updated 26 October 2023
We carried out this announced comprehensive inspection on 17 August 2023 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 advisor.
To get to the heart of patients’ experiences of care and treatment, we always ask the following 5 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:
- The dental clinic appeared clean and well-maintained.
- The practice had infection control procedures which reflected published guidance.
- Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
- The practice had systems to manage risks for patients, staff, equipment and the premises.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The practice had staff recruitment procedures which reflected current legislation.
- Clinical staff provided patients’ care and treatment in line with current guidelines.
- Patients were treated with dignity and respect. Staff took care to protect patients’ privacy and personal information.
- Staff provided preventive care and supported patients to ensure better oral health.
- The appointment system worked efficiently to respond to patients’ needs.
- The frequency of appointments was agreed between the dentist and the patient, giving due regard to National Institute of Health and Care Excellence (NICE) guidelines.
- There was effective leadership and a culture of continuous improvement.
- Staff felt involved, supported and worked as a team.
- Staff and patients were asked for feedback about the services provided.
- Complaints were dealt with positively and efficiently.
- The practice had information governance arrangements.
Background
Lighthouse Dental Practice is in Southsea, Hampshire and provides private dental care and treatment for adults and children.
Access to the practice is via a flight of steps, therefore is not accessible for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for disabled people, are available near the practice. The practice has made reasonable adjustments to support patients with access requirements.
The dental team includes 4 dentists, 4 dental nurses, 3 dental hygienists, a practice manager and 2 receptionists. The practice has 4 treatment rooms.
During the inspection we spoke with 2 dentists, 2 dental nurses, a dental hygienist, and a receptionist. We looked at practice policies, procedures, and other records to assess how the service is managed.
The practice is open: 8:30am – 5pm Monday to Friday. The practice is closed between 1-2pm.
There were areas where the provider could make improvements. They should:
- Improve the practice’s infection control procedures and protocols 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, used instruments should be kept moist until decontaminated, water temperatures should be logged daily, infection prevention and control audits should reflect current practice and cleaning schedules should be completed accurately.
- Implement an effective system of checks of medical emergency equipment and medicines taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.
- Improve the practice's processes for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken and the products are stored securely.
- Improve the practice's recruitment policy and procedures to ensure accurate, complete and detailed records are maintained for all staff.
- Take action to ensure that all clinical staff have adequate immunity for vaccine preventable infectious diseases.
Develop systems to ensure an effective process is established for the on-going assessment, supervision and appraisal of all staff, including the training, learning and development needs of individual staff members at appropriate intervals.