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Reports


Inspection carried out on 23 July 2019

During a routine inspection

We carried out this announced inspection on 23 July 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

Bawtry Dental Practice is in Bawtry, Doncaster and provides NHS and private dental treatment to adults and children. The practice also provides an NHS orthodontic service.

There is a single step access into the practice for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice on local roads and car parks.

The dental team includes two principal dentists and four associate dentists, one of whom was a foundation training dentist and one was the orthodontist. There were seven dental nurses and an orthodontic dental nurse, one dental hygiene therapist and a receptionist. The practice has four treatment rooms and an instrument decontamination room.

The practice is owned by a company and as a condition of registration must have a person registered with the Care Quality Commission 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 Bawtry Dental Practice is one of the principal dentists.

On the day of inspection, we collected 17 CQC comment cards filled in by patients. All comments reflected positively on the service.

During the inspection we spoke with three dentists and two dental nurses and the orthodontic dental nurse. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday, Wednesday and Thursday 8am to 5:30pm

Tuesday 8am to 7:30pm

Friday 8am to 4pm

The practice is also open one Saturday per month.

Our key findings were:

  • The practice appeared clean and well maintained.
  • The provider had infection control procedures which reflected published guidance, some adjustments could be made to ensure full compliance.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
  • The provider had systems to help them manage risk to patients and staff. We identified some areas where improvements could be made to Legionella management systems and incident identification and reporting.
  • The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • 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 provided preventive care and supporting patients to ensure better oral health.
  • The appointment system took account of patients’ needs.
  • The provider had effective leadership and culture of continuous improvement. Adjustments could be made to have more oversight of the infection, prevention and control audits.
  • 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 system for recording, investigating and reviewing incidents or significant events with a view to preventing further occurrences and ensuring that improvements are made as a result.
  • 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: Oversight of the Legionella management systems and compliance of the required actions identified in the risk assessment.
  • Review the practice’s infection control procedures and protocols 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: a review of the layout of the decontamination room, accurate audit recording and validation of the sterilisers using the data logger.