Updated 11 February 2022
We carried out this announced focused inspection on 11 January 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 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 further inspector and a specialist dental adviser.
To get to the heart of patients’ experiences of care and treatment, we asked the following questions:
• 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 practice appeared to be visibly clean and well-maintained.
- The provider had infection control procedures which reflected published guidance.
- 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.
- 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. These were not always applied.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- The provider had effective leadership and a culture of continuous improvement.
- Staff felt involved and supported and worked 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 information governance arrangements.
Background
Holywell House Hinckley is in Hinckley, Leicestershire, and specialises in orthodontic treatment and minor oral surgery alongside NHS and private general dental care and treatment for adults and children.
There is level 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 dental team works across all four of the providers services and includes eight dentists, 17 dental nurses, of whom three are trainees, one dental hygienist, one dental therapist, a clinical dental technician three receptionists, four practice support staff, including a practice manager and one business manager. The practice has four treatment rooms.
During the inspection we spoke with two dentists, three dental nurses, the clinical lead, two receptionists the practice manager and the business manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday from 9am to 6.30pm
Tuesday from 9am to 5pm
Wednesday from 9am to 6pm
Thursday from 9am to 6pm
Friday from 8.30am to 3pm – occasionally to 6.30pm
Saturday from 8am to 3pm
We identified an area of notable practice.
- The provider had developed procedures, including training for staff and a range of materials and support, to improve access to treatment for patients living with autism.
There were areas where the provider could make improvements. They should:
- Take action to ensure clinicians record in the patients’ dental care records or elsewhere the reason for taking X-rays, a report on the findings and the quality of the image in compliance with Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance HPA-CRCE-010 Guidance on the Safe Use of Dental Cone Beam (Computed Tomography).
- Implement an effective recruitment procedure to ensure that appropriate checks are completed prior to new staff commencing employment at the practice. In particular, to ensure that references are sought from confirmed previous employers.
- Improve and develop the practice's policies and procedures for obtaining and recording patient consent to care and treatment to ensure they are in compliance with legislation, taking into account relevant guidance, and for staff to follow them.