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Reports


Inspection carried out on 11 November 2019

During a routine inspection

We carried out this unannounced inspection on 11 November 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

Coulsdon Dental Clinic is in the London borough of Croydon and provides NHS and private dental treatment to adults and children.

There is level access via a portable ramp for people who use wheelchairs and those with pushchairs. Car parking spaces are available at the front of the practice and on surrounding roads near the practice.

The dental team includes one principal dentist, four associate dentists, one dental nurse (who also undertook practice management duties), three trainee dental nurses, two dental hygienists, and one receptionist (who is also a qualified dental nurse and provides cover). The practice has two treatment rooms.

The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.

We were unable to collect feedback from patients on the day of the inspection. However, we reviewed feedback provided by patients through the provider’s patients’ satisfaction surveys. The feedback was very positive.

During the inspection we spoke with the principal dentist, one dental nurse, two trainee dental nurses, one dental hygienist and the receptionist. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

8.00am-6.00pm Monday, Tuesday and Thursdays;

9.00am-5.00pm Wednesdays;

9.00am-2.00pm Fridays and

8.30am-2.00pm Saturdays.

Our key findings were:

  • The practice appeared clean and 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 suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • The provider had 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 supported patients to ensure better oral health.
  • The appointment system took account of patients’ needs.
  • The provider had effective leadership and culture of continuous improvement.
  • 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 protocols regarding audits for prescribing of antibiotic medicines taking into account the guidance provided by the Faculty of General Dental Practice.

  • Take action to ensure audits of infection prevention and control are undertaken at regular intervals to improve the quality of the service. Practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.

  • Improve the practice's recruitment policy and procedures to ensure accurate, complete and detailed records are maintained for all staff.
  • Take action to implement any recommendations in the practice's fire safety risk assessment and ensure ongoing fire safety management is effective.