Updated 28 June 2023
We carried out this announced comprehensive inspection on 30 May 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.
- Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
- The practice had some systems to manage risks for patients, staff, equipment and the premises.
- Improvements to the practice’s infection control procedures were needed to ensure they fully reflected published guidance.
- Improvements could be made giving regard to the handling of sharps instruments and the use of X-ray equipment.
- 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.
- A review of current protocols with regard to the use of closed-circuit television cameras was needed.
- 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
Bupa Dental Care - Doncaster is part of Bupa, a dental group provider.
The practice is in Doncaster and provides NHS and private dental care and treatment for adults and children.
The practice is located on the first floor in between a row a shops. Access up to the practice is via a single flight of stairs. If patients require step free access into the practice, they are directed to a sister practice within the group. Car parking spaces are available near the practice.
The dental team includes 4 dentists, 7 dental nurses (2 of whom are trainees), 2 practice managers and a dedicated receptionist. The practice has 4 treatment rooms, 1 of which is currently operating as the instrument processing and decontamination room due to ongoing refurbishment.
During the inspection we spoke with 2 dentists, 2 dental nurses and the practice managers. We looked at practice policies, procedures and other records to assess how the service is managed.
The practice is open: Monday to Friday 8am to 5.30pm.
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, more effective use of the light magnifier and appropriate reprocessing of instruments.
- Improve the practice’s sharps procedures to ensure the practice is in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
- Improve the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment.
- Improve current protocols for the use of closed-circuit television cameras taking into account the guidelines published by the Information Commissioner's Office.