20 October 2021
During an inspection looking at part of the service
We carried out this announced inspection on 20 October 2021 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 questions:
• Is it safe?
• Is it effective?
• 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 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 well-led?
We found that this practice was providing well-led care in accordance with the relevant regulations.
Background
Bupa Dental Care Peterborough - Broadway is a well-established practice which provides both NHS and private treatment to adults and children. The dental team includes seven dentists, one dental hygienist, 13 dental nurses, five receptionists and a practice manager. The practice has eight treatment rooms.
The practice opens on Mondays, Tuesdays, Wednesdays and Fridays from 8am to 5pm; and on Thursdays from 8am to 7pm.
The practice has its own parking facilities, and there is on street parking nearby. Wheelchair access is available via a ramp, and there is a fully accessible toilet and ground floor treatment rooms.
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 the practice is the practice manager.
During our inspection we spoke with two dentists, the dental hygienist, the practice manager, three nurses and reception staff. We looked at practice policies and procedures and other records about how the service is managed.
Our key findings were:
- The practice appeared clean and well maintained.
- Infection control procedures reflected published guidance.
- Staff knew how to deal with emergencies, and appropriate medicines and life-saving equipment were available.
- The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The practice had thorough staff recruitment procedures.
- Patients’ care and treatment was provided in line with current guidelines.
- The practice took complaints and concerns seriously and responded to them appropriately to improve the quality of care.
- There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted upon.
There were areas where the provider could make improvements. They should:
- Take action to implement the recommendations in the practice's legionella risk assessment and ensure ongoing legionella management is effective.
- Take action to ensure the clinicians take into account the guidance provided by the Faculty of General Dental Practice when completing dental care records. In particular, in relation to the recording of patients’ caries and periodontal disease risk levels.
- Implement protocols for the use of closed-circuit television cameras taking into account the guidelines published by the Information Commissioner's Office. In particular, ensuring patients are made aware that they are being filmed in communal areas of the practice.
- 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. In particular, ensuring the radiation protection supervisor has appropriate training for their role.