Dental Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We found this practice was not providing effective care in accordance with the relevant regulations. We will be following up on our concerns to ensure the provider has made the required improvements.

During our inspection of this key question, we found concerns related to the completeness of patient care records. In addition, the practice did not have policies and procedures for obtaining patient consent to care and treatment in line with legislation.

These concerns were in breach of Regulation 17 Good governance.

You can find more details of our concerns in the detailed findings below.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The judgement for Assessing needs is based on the latest evidence we assessed for the Effective key question.

We looked at 4 patient care records. The information recorded in these patient care records was not in line with recognised guidance. In particular, risk assessments, diagnosis, treatment options and costs were not consistently documented, and radiographs were not routinely reported on and justified. We noted a clinical records audit had been completed but did not reflect the concerns identified on the inspection day.

Patient care records did not demonstrate that valid consent was obtained. There was no evidence that risks, options and benefits of treatment choices were discussed with patients to obtain informed consent.

The practice did not have a consent policy in place. 

The practice had ineffective systems for prescribing of medicines. In particular, the dose, frequency and justification of antibiotics was not consistently recorded.

Patients were referred to primary and secondary care specialists for treatment the practice did not provide. This included referring patients with suspected cancer under the national faster diagnosis pathways.

The judgement for How staff, teams and services work together is based on the latest evidence we assessed for the Effective key question.

The judgement for Supporting people to live healthier lives is based on the latest evidence we assessed for the Effective key question.

The judgement for Monitoring and improving outcomes is based on the latest evidence we assessed for the Effective key question.

The judgement for Consent to care and treatment is based on the latest evidence we assessed for the Effective key question.