We carried out this announced inspection on 13 August 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 not 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 not providing well-led care in accordance with the relevant regulations.
Background
Queens Head Dental Surgery is in Oldbury and provides NHS and private treatment to adults and children.
There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces, including one for blue badge holders, are available immediately outside the practice.
The dental team includes one dentist, one dental nurse, one dental hygienist and one receptionist. The practice has two treatment rooms and a separate room for carrying out decontamination.
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.
On the day of inspection, we collected 13 CQC comment cards that had been completed by patients. We spoke with the dentist, dental nurse and receptionist. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday – Friday: 9am to 5:30pm
Saturdays: by appointment only
Our key findings were:
- The practice appeared clean and well maintained, although we identified some areas that required improvement.
- The provider had infection control procedures which mostly reflected published guidance. Some improvements were required.
- Staff knew how to deal with emergencies but training for some staff members was overdue. One medicine had expired and some items of equipment were missing.
- The practice had limited 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. Improvements were needed to ensure the availability of complete immunisation records for one clinical staff member. Information was missing from one staff member’s personnel file. Their reference did not include their name and was undated.
- The clinical staff provided patients’ care and treatment in line with current guidelines however improvements were required.
- 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.
- 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.
- Governance processes were not sufficiently effective.
We identified regulations the provider was not complying with. They must:
- Ensure care and treatment is provided in a safe way to patients.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Full details of the regulation the provider is not meeting is at the end of this report.
There were areas where the provider could make improvements. They should:
- Review the practice's protocols for patient assessments and ensure they are in compliance with current legislation and take into account relevant nationally recognised evidence-based guidance.