Updated 27 June 2022
We carried out this announced focused inspection on Wednesday 25 May 2022 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 adviser.
To get to the heart of patients’ experiences of care and treatment, we usually ask five key questions, however due to the ongoing COVID-19 pandemic and to reduce time spent on site, only the following three questions were 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:
- The dental clinic appeared to be visibly clean and well-maintained.
- The practice had infection control procedures which reflected published guidance.
- Staff knew how to deal with medical emergencies. Action was needed to obtain an appropriate emergency medicine; this was acted on immediately.
- The practice had systems to help them manage risk to patients and staff. Improvements could be made to the systems to assess sharps and Legionella risks.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The practice had staff recruitment procedures which reflected current legislation.
- The clinical staff provided patients’ care and treatment in line with current guidelines. Systems should be reviewed to ensure audits of clinical care are effective.
- Patients were treated with dignity and respect and staff took care to protect their privacy and personal information.
- Staff provided preventive care and supported patients to ensure better oral health.
- There was effective leadership and a culture of continuous improvement.
- Staff felt involved and supported and worked as a team.
- Staff and patients were asked for feedback about the services provided.
Background
Dewsbury Road Dental Practice is in Leeds and provides NHS and private dental care and treatment for adults and children.
There is level access to the practice for people who use wheelchairs and those with pushchairs. Street parking is available near the practice. A ramp is provided at a side door for wheelchair users.
The dental team includes five dentists, seven dental nurses (including four trainees) who also undertake reception duties, a dental hygienist, and a practice manager. The practice has four treatment rooms.
During the inspection we spoke with two dentists, three dental nurses, the practice manager and a company regional compliance manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday to Thursday 9am to 6pm
Friday 9am to 5pm
The practice had taken steps to improve environmental sustainability. For example, by using technology to reduce paper usage. The company were working with a sustainability consultancy to reduce their environmental impact.
There were areas where the provider could make improvements. They should:
- Improve the practice’s sharps procedures to ensure the practice is in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
- Take action to ensure the availability of emergency medicines in the practice to manage medical emergencies taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.
- Take action to implement any recommendations in the practice's Legionella risk assessment, 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, acting on water temperatures outside the accepted range.
- Take action to ensure audits have documented learning points and the resulting improvements can be demonstrated.