Updated 13 June 2019
We carried out this announced inspection on 30 April 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 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 providing well-led care in accordance with the relevant regulations.
Background
Mere Green Dental Care is in Sutton Coldfield and provides NHS and private treatment to adults and children.
The practice is situated on the first floor and there is no level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice within a public car park.
The dental team includes two dentists, one dental nurse and one receptionist. The practice has one treatment room although the practice is currently undergoing renovation to include an additional treatment room and a separate room for carrying out decontamination.
The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.
On the day of inspection, we collected 34 CQC comment cards filled in by patients.
During the inspection we spoke with two dentists, one dental nurse and the receptionist. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday / Tuesday / Thursday: 8.30am – 5pm
Wednesday: 8.30am – 6pm
Friday: 1pm – 5pm
Our key findings were:
- The practice appeared clean and well maintained.
- The provider had infection control procedures which mostly reflected published guidance. Improvements were made to strengthen processes within 48 hours of our inspection.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- The practice had systems to help them manage risk to patients and staff.
- The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children. All staff had completed training in safeguarding.
- The provider had thorough staff recruitment procedures.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
- Staff were providing preventive care and supporting patients to ensure better oral health.
- The appointment system took account of patients’ needs.
- The provider had effective leadership and a culture of continuous improvement.
- Staff felt involved and supported and worked well as a team.
- The provider asked staff and patients for feedback about the services they provided.
- The provider dealt with complaints positively and efficiently.
- The provider had suitable information governance arrangements.
There were areas where the provider could make improvements. They should:
- Review the practice's Legionella risk assessment and implement any recommended actions, 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, ensuring that staff are carrying out safety checks in line with guidance.
- Review staff awareness of the requirements of the Mental Capacity Act 2005 and Gillick competency, and ensure all staff are aware of their responsibilities under the Act as it relates to their role.