Updated 8 June 2023
We carried out this announced comprehensive inspection on 31 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:
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- 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.
- Staff felt involved, supported, and worked as a team.
- Patients were asked for feedback about the services provided.
- The practice had information governance arrangements.
- The dental clinic needed refurbishment.
- The practice had infection control procedures which broadly reflected published guidance. However, improvements were needed to ensure adherence to the regulations.
- Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available. However, on the day we found the defibrillator pads had expired in 2020.
- We found shortfalls in assessing and mitigating risks in relation to substances hazardous to health, equipment maintenance, infection control, fire and sharps injury.
- The practice had staff recruitment procedures which reflected current legislation, however, not all staff files included all the necessary employment information.
- Improvements were needed in relation to the practice governance arrangements and quality assurance processes.
- Policies and procedures were in place to govern most activities except for closed circuit television.
Background
The provider has 3 dental practices, and this report is about Wellesley House Dental Practice.
Wellesley House Dental Practice is in Ilford in the Northeast London Borough of Redbridge and provides mainly NHS and some private dental care and treatment for adults and children. The practice is also used as an urgent hub where NHS 111 refers patients in need of urgent and emergency dental care and treatment.
There are two wide steps at the entrance to the practice which means that it was not accessible for people who use wheelchairs and those with pushchairs. Car parking spaces, including parking for disabled people, are available near the practice.
The dental team includes the principal dentist, 3 associate dentists, 2 qualified dental nurses, 1 receptionist and 1 administrator. They are supported by a practice manager who worked peripatetically to support all three practices. The practice has 2 treatment rooms.
During the inspection we spoke with 2 dentists, 2 dental nurses and the practice manager. We looked at practice policies, procedures and other records to assess how the service is managed.
The practice is open Monday to Friday from 9am to 5pm.
We identified regulations the provider was not complying with. They must:
- Ensure care and treatment is provided in a safe way to patients.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Full details of the regulations the provider was not meeting are at the end of this report.
There were areas where the provider could make improvements. They should:
- Improve the practice protocols regarding auditing patient dental care records to check that necessary information is recorded.
- Implement audits for prescribing of antibiotic medicines taking into account the guidance provided by the College of General Dentistry.
- Improve the practice's systems for assessing, monitoring, and mitigating the various risks arising from the undertaking of the regulated activities. In particular: lone working.