Updated 27 May 2021
We carried out this announced inspection on 28 April 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 Care Quality Commission, (CQC), inspector who was supported by a specialist dental adviser.
As part of this inspection we asked:
• 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 this practice was providing safe care in accordance with the relevant regulations.
Are services effective?
We found this practice was providing effective care in accordance with the relevant regulations.
Are services well-led?
We found this practice was providing well-led care in accordance with the relevant regulations.
Background
Pershore Smiles is in Pershore and provides private dental care and treatment for adults and children.
There is one step providing access to the practice which could make access for people who use wheelchairs and those with pushchairs difficult. The practice notifies all new patients of the access limitations and signposts them to fully accessible practices where appropriate. Car parking spaces, including dedicated parking for people with disabilities, are available near the practice.
The dental team includes the principal dentist, a business manager, three dental nurses (two of whom are apprentice dental nurses), one dental hygienist and one receptionist. The practice has two treatment rooms and a separate decontamination room.
The practice is owned by an organisation and as a condition of registration they must have a person registered with the CQC 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 Pershore Smiles is the principal dentist.
During the inspection we spoke with the principal dentist, one qualified dental nurse and one apprentice dental nurse. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday from 9am to 1pm
Tuesday from 9am to 5pm
Wednesday from 9am to 1pm
Thursday from 9am to 5pm
(9am to 7pm once a month)
Friday from 8am to 12pm
Saturday – By Appointment
Our key findings were:
- The practice appeared to be visibly clean and well-maintained.
- The provider had infection control procedures which mostly reflected published guidance. Dip slide testing had not been completed on dental water lines in accordance with manufacturers guidance.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- The provider had some systems to help them manage risk to patients and staff. We found shortfalls in appropriately assessing and mitigating risks in relation to radiography, care of substances hazardous to health and fire management. Immediate action was taken within 48 hours of our inspection to address most of these shortfalls.
- The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The provider had staff recruitment procedures which reflected current legislation.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Staff provided preventive care and supported patients to ensure better oral health.
- Staff felt involved and supported and worked as a team.
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 the guidance for Dental Practitioners on the Safe Use of X-ray Equipment.
- Take action to implement any recommendations in the practice's fire safety risk assessment and ensure ongoing fire safety management is effective. In particular, completing regular fire drills and ensuring fire marshal training is in date.
- Improve the practice's processes for the control of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure safety data sheets are retained alongside the completed risk assessments.