Updated 20 November 2023
We carried out this announced comprehensive inspection on 31 October 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.
- The practice had infection control procedures which mostly reflected published guidance.
- Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
- The practice had systems to manage risks for patients, staff, equipment and the premises.
- 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. We found these were not always implemented consistently.
- 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.
- Staff and patients were asked for feedback about the services provided.
- Complaints were dealt with positively and efficiently.
- There was effective leadership, however there was scope for improvement with audits and recruitment.
Background
Family Dental Centre is in Great Barr, Birmingham and provides NHS and private dental care and treatment for adults and children.
There is step free access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for people with disabilities, are available near the practice. The practice has made reasonable adjustments to support patients with access requirements.
The dental team includes 5 dentists, 6 dental nurses, 1 dental hygienist, 1 dental therapist, 1 practice manager and 1 receptionist. The practice has 4 treatment rooms.
During the inspection we spoke with 3 dentists, 4 dental nurses, the receptionist 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 Thursday from 8am to 5pm.
Friday from 8am to 4pm.
Saturday from 9am to 1pm – hygienist appointments only.
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, a few minor processes in the decontamination room could be improved.
- Improve the practice's recruitment policy and procedures to ensure accurate, complete and detailed records are maintained for all staff.
- Implement protocols for domiciliary visits taking into account the 2009 guidelines published by British Society for Disability and Oral Health in the document “Guidelines for the Delivery of a Domiciliary Oral Healthcare Service”.
- Take action to ensure audits of radiography, infection prevention and control and antimicrobial prescribing are undertaken at the recommended intervals to improve the quality of the service and follow the appropriate guidelines. The practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.