Archived: Chapel Dental

We carried out this announced focused inspection on 18 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 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 in place which reflected published guidance. However, we found equipment was not maintained in accordance with manufacturer’s instructions.
• Staff knew how to deal with emergencies.
• 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 medicines management, antimicrobial prescribing and legionella management.
• 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.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• Staff provided preventive care and supported patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• 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.

Background

Chapel Dental is in Great Wilbraham 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. Car parking spaces, including dedicated parking for people with disabilities are available near the practice.

The dental team includes eight dentists, nine dental nurses, two dental hygienists who are also dental therapists, 2 receptionists and two practice managers. The practice has six treatment rooms.

During the inspection we spoke with three dentists, three dental nurses, one dental therapist/dental hygienist and both practice managers. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open on weekdays from 9am until 5pm.

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

• Improve the practice's protocols for medicines management and ensure all medicines are stored and dispensed of safely and securely.
• Carry out a Legionella risk assessment and 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.’
• Review the practice's systems for checking and monitoring equipment taking into account relevant guidance and ensure that all equipment is well maintained. In particular ensuring that autoclaves are serviced and maintained in accordance with manufacturer’s instructions.