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Stanstead Road Dental Practice Limited


Inspection carried out on 9 May 2019

During a routine inspection

We carried out this announced inspection on 9 May 2019 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 not 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 not providing well-led care in accordance with the relevant regulations.


Stanstead Rd Dental Practice Limited is in the London borough of Lewisham 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 for limited periods.

The dental team includes one dentist, one dental nurse, one trainee dental nurse, one dental practice manager and a company director. The practice has two treatment rooms, however, only one is currently in use.

The practice is owned by a company and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run. The registered manager at Stanstead Rd Dental Practice Limited is the company director. A registered manager is legally responsible for the delivery of services for which the practice is registered

On the day of inspection received feedback from three patients.

During the inspection we spoke with the dentist, the dental nurse, the company director 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 -8.30am - 5.45pm

Tuesday-10am -7.45pm

Wednesday and Thursday -9am -5.45pm

Friday -9am -4.45pm

Our key findings were:

  • The practice appeared clean and well maintained.
  • The provider had infection control procedures which reflected published guidance.
  • The provider had appropriate staff recruitment procedures.
  • The provider asked patients for feedback about the services they provided.
  • The clinical staff provided patients’ care and treatment in line with current guidelines.
  • The provider had systems to deal with complaints efficiently.
  • The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • Staff treated patients with dignity and respect; however, they did not always take care to protect their privacy and personal information.
  • Staff were providing preventive care and supporting patients to ensure better oral health.
  • The appointment system did not always take into account of patients’ needs.
  • Staff did not always feel involved and supported.
  • Staff knew how to deal with emergencies. However, not all emergency medicines and life-saving equipment, was available as per national guidance.
  • There was no emergency lighting and no fire detection system in place.
  • An up to date fire risk assessment was not available. The previous risk assessment was undertaken in 2010 and not all recommendations had been completed.
  • The provider did not have suitable arrangements to ensure the safety of the X-ray equipment.
  • There were ineffective governance arrangements in place.
  • There were insufficient systems in place to manage risk to patients and staff.
  • The provider did not demonstrate effective leadership nor was there a culture of continuous improvement.

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

  • Ensure that care and treatment is provided to patients in a way that is safe
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulations the provider is not meeting are at the end of this report.

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

Review the availability of an automated external defibrillator, (AED), in the practice to manage medical emergencies, taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council, and undertake a risk assessment if a decision is made not to have an AED on site.

Review the practice’s arrangements for receiving and 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.

Review the practice's protocol and staff awareness of their responsibilities in relation to the duty of candour to ensure compliance with The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Inspection carried out on 1 November 2013

During a routine inspection

During our visit we spoke to three people using the service. They said "I've had information provided verbally and using leaflets. As a child my daughter had the importance of teeth cleaning explained and how to do it", "I've been coming here a long time, I left but wasn't happy so I came back" and "I wouldn't come back if I wasn't happy".

People told us that they were treated with dignity and respect and we saw that they were by staff during our visit.

They were given the information and time they needed to decide if this was the treatment they wanted and the practice they wished to provide it.

The procedure for consultation and treatment was fully explained including the fees charged.

People were told about any risks that might arise from the treatment chosen and had received consultations and treatment in a way that maintained their privacy.

They did not comment on the practice infection control system or number of staff available to meet their treatment needs.

They did tell us they thought the practice was kept clean and tidy. They felt safe using the service and staff were very competent friendly and helpful. "Everyone is very friendly and has always has been".

We found that the practice gave suitable information so that people could make an informed decision if they wished to proceed with the treatment recommended. "I get enough information about treatment and reason it is needed"

Records were kept up to date and there was a robust complaints procedure that was followed and people were aware of. "I'm a retired nurse and would be the first to complain".

There were adequate numbers of suitably qualified staff to meet people's needs.