Archived: Alma Terrace

We carried out this announced comprehensive inspection on 20 September 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 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:

• The dental clinic was visibly clean and well-maintained.
• The practice had systems to help them manage risk to patients and staff.
• Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
• Patients were treated with dignity and respect and staff took care to protect their personal information.
• Staff provided preventive care and supported patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• Staff felt involved and supported and worked as a team.
• Staff and patients were asked for feedback about the services provided.
• Complaints were dealt with positively and efficiently.
• The practice had staff recruitment procedures which reflected current legislation. However, improvements could be made to ensure relevant pre-employment checks were carried out at the time of recruitment.
• Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available. The introduction of a temperature monitoring protocol was needed to ensure temperature-sensitive medicines were stored appropriately.
• The practice had infection control procedures which reflected published guidance. However, improvements could be made to the fixtures and fittings in the decontamination room.
• Improvements were needed to the systems used to help the provider manage risks to patients and staff.

Background

The provider has 3 practices and this report is about Alma Terrace.

The practice is in Silloth in Cumbria and provides NHS and private dental care and treatment for adults and children.

The practice is located in a mid-terrace converted house. The surgery is located on the first floor and accessible only by stairs. Car parking spaces are available outside the practice.

The dental team includes 1 dentist, 1 dental nurse, 1 receptionist and 1 practice manager/dental nurse. The practice has 1 treatment room.

During the inspection we spoke with the dentist, the dental nurse, the receptionist and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday, Tuesday and Thursday from 9am to 1pm and from 2pm to 7pm

Wednesday from 9am to 1pm

Friday 9am to 2pm

We identified regulations the provider was not complying with. They must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulation the provider was not meeting are at the end of this report.

There were areas where the provider could make improvements. They should:

• Implement practice protocols and procedures to ensure staff are up to date with their mandatory training and continuing professional development.
• 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 relating to the fixtures and fittings in the decontamination room.
• Introduce protocols for monitoring and recording the fridge temperature to ensure that medicines and dental care products are being stored in line with the manufacturer’s guidance.