Lilac House Specialist Dental Practice

We carried out this announced comprehensive inspection on 27 March 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.
• Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The practice had infection control procedures which did not fully reflect published guidance.
• Staff knew how to deal with medical emergencies; all required medicines were available and except for one item, all required life-saving equipment was available.
• Systems to ensure staff received medical emergency training in line with published guidance could be improved.
• The practice had systems to manage risks for patients, staff, equipment, and the premises; improvement was needed in some areas.
• The practice had staff recruitment procedures which reflected current legislation.
• Clinical staff provided patients’ care and treatment in line with current guidelines.
• Procedures for obtaining patient consent, responding to patient safety alerts, and monitoring referrals could be improved.
• 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, The British Society of Periodontology and Prosthodontics.
• Improvement was needed to ensure governance was effective, systems were embedded, and these followed published guidance.
• Systems to ensure audits were accurately reflected could be improved.
• Staff felt involved, supported, and worked as a team.
• Systems were not in place ensure the on-going assessment, supervision, and appraisal of staff.
• 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

Lilac House Specialist Dental Practice is in Acomb, York and provides private periodontal and prosthodontic dental care and treatment.

There is step free access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces are available at the practice. The practice has made reasonable adjustments to support patients with access requirements.

The dental team includes 2 dentists, 1 dental nurse and a dental therapist. The practice has 2 treatment rooms.

During the inspection we spoke with both dentists and the dental nurse. We looked at practice policies, procedures, and other records to assess how the service is managed.

The practice is open: Monday to Thursday 9am – 5.30pm

We identified regulations the provider was not complying with. They must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulation the provider was not meeting are at the end of this report.

There were areas where the provider could make improvements. They should:

• Take action to ensure staff have received training to manage medical emergencies taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.
• Implement an effective system for responding to patient safety alerts, recalls and rapid response reports issued by the Medicines and Healthcare products Regulatory Agency, the Central Alerting System, and other relevant bodies, such as Public Health England.
• Improve and develop the practice's policies and procedures for obtaining patient consent to care and treatment to ensure they are in compliance with legislation, take into account relevant guidance, and staff follow them.
• Implement a system to ensure patient referrals to other dental or health care professionals are centrally monitored to ensure they are received in a timely manner and not lost.
• Take action to ensure audits of radiography and infection prevention and control accurately reflect systems in place to improve the quality of the service. Practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.