Updated 20 December 2023
We carried out this announced comprehensive inspection on 20 November 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 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. Improvement was required in relation to risk.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- Improvements were needed to the staff recruitment procedures to ensure essential checks are in place.
- 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.
- Staff felt involved, supported and worked as a team.
- Practice protocols and procedures in relation to the safe use of cone-beam computed tomography (CBCT) needed to be improved.
- 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
Fulwell Clinic is in Sunderland and provides urgent 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. On street parking was available near the practice. The practice has made reasonable adjustments to support patients with access requirements.
The dental team includes 5 dentists, 11 dental nurses, 2 dental hygienists, 1 practice manager and a receptionist. The practice has 6 treatment rooms.
During the inspection we spoke with 3 dentists, 5 dental nurses, 1 dental hygienist, 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 Friday from 08:45am – 5:00pm
There were areas where the provider could make improvements. They should:
- 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 Health Protection Agency - Centre for Radiation, Chemical and Environmental Hazards. (HPA-CRCE-010) [RC1] Guidance on the Safe Use of Dental Cone Beam CT (Computed Tomography).
- Implement an effective recruitment procedure to ensure that appropriate checks are completed prior to new staff commencing employment at the practice.
- Take action to ensure that all clinical staff have adequate immunity for vaccine preventable infectious diseases.
Improve the practice’s sharps procedures to ensure the practice is in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013
[RC1]You need to write that out in full - Health Protection Agency - Centre for Radiation, Chemical and Environmental Hazards.