Updated 15 March 2024
We carried out this announced comprehensive inspection on 23 February 2024 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. Most appropriate medicines and life-saving equipment were available.
- The practice did not have effective 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 staff recruitment procedures reflected current legislation. These were not applied 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.
- There was a lack of effective leadership and processes for continuous improvement.
- Staff felt involved, supported and worked as a team.
- Shortfalls were found with complaints management to show they were dealt with positively and efficiently.
- The practice had information governance arrangements.
Background
Serenity Dental Practice is in Rugeley, Staffordshire and provides NHS and private dental care and treatment for adults and children.
There is a portable ramp for 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 2 dentists, 1 qualified dental nurse, 2 trainee dental nurses, 1 dental hygienist and a practice manager. The practice has 2 treatment rooms.
During the inspection we spoke with 1 dentist, the qualified dental nurse, 1 trainee dental nurse 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 9am to 6pm
Friday from 9am to 5pm
We identified regulations the provider was/is 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:
- Develop systems to ensure an effective process is established for the on-going assessment, supervision and appraisal of all staff. Including the training, learning and development needs of individual staff members at appropriate intervals.