Updated 15 June 2018
We carried out this announced inspection on 10 April 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
College Road Dental Practice is in Birmingham and provides NHS and private treatment to adults and children.
There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice. There were no dedicated spaces for blue badge holders but staff said patients were able to park on the driveway if they informed the practice in advance.
The dental team includes five dentists, six dental nurses (two of whom are trainees) and one receptionist. There is one practice manager who is also qualified as a dental nurse. The practice has three treatment rooms.
The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.
On the day of inspection we collected 50 CQC comment cards filled in by patients.
During the inspection we spoke with two dentists, two dental nurses, the receptionist 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 Thursday between 8.30am and 5.30pm and between 8.30am and 5pm on a Friday. The practice also offers extended opening hours on Thursday evenings to 7pm and Saturdays between 8am and 12pm.
Our key findings were:
- The practice appeared clean and well maintained.
- The practice had infection control procedures which reflected published guidance. Some improvements were required and were carried out immediately. Some further improvements will be carried out when the practice undergoes major refurbishment in September 2018.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available with the exception of a few items which were ordered as soon as we brought this to the attention of the provider.
- The practice had systems to help them manage risk.
- The practice staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
- The practice had thorough staff recruitment procedures. We identified necessary improvements and these were implemented immediately.
- The clinical staff mostly provided patients’ care and treatment in line with current guidelines. We identified some necessary improvements and the provider assured us they would make the necessary changes through staff meetings and audits.
- Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
- The practice was providing preventive care and supporting patients to ensure better oral health.
- The appointment system met patients’ needs.
- The practice had effective leadership and culture of continuous improvement.
- Staff felt involved and supported and worked well as a team.
- The practice asked staff and patients for feedback about the services they provided.
- The practice staff dealt with complaints positively and efficiently.
- The practice staff had suitable information governance arrangements.
There were areas where the provider could make improvements. They should:
- Review 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 the decontamination area in the practice.
- Review the practice's protocols for completion of dental care records taking into account the guidance provided by the Faculty of General Dental Practice. Staff should also review the practice's protocols for patient assessments and ensure they are in compliance with current legislation and take into account relevant nationally recognised evidence-based guidance.
- Review the practice’s protocols to ensure audits of radiography and infection prevention and control are undertaken at regular intervals to improve the quality of the service. The practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.