Updated 16 June 2021
We carried out this announced inspection on 25 May 2021 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.
As part of this inspection we asked:
• 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:
Are services safe?
We found this practice was providing safe care in accordance with the relevant regulations.
Are services effective?
We found this practice was providing effective care in accordance with the relevant regulations.
Are services well-led?
We found this practice was providing well-led care in accordance with the relevant regulations.
Background
Antrim House is in Bushbury, Wolverhampton and provides NHS and private dental care and treatment for adults and children.
There is ramped access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces are available in the dedicated practice car park. The car park had recently been extended to allow for additional parking, at the time of our inspection the provider told us that they planned to mark out dedicated spaces for blue badge holders.
The dental team includes seven dentists, six dental nurses (three of whom are trainee dental nurses), one dental hygiene therapist, three receptionists and a practice manager. The practice has six treatment rooms.
The practice is owned by a partnership and as a condition of registration must have a person registered with the CQC as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run. The registered manager at Antrim House is the practice manager.
During the inspection we spoke with three dentists, two dental nurses, two receptionists 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 to Thursday from 9am to 6pm.
Friday from 9am to 4pm.
Our key findings were:
- The practice was undergoing extensive refurbishment and renovation works at the time of our inspection. The provider had taken ownership of the practice in May 2019 and had a refurbishment plan in place to upgrade treatment rooms and patient facilities.
- 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.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Staff provided preventive care and supported patients to ensure better oral health.
- The provider had effective leadership and a culture of continuous improvement.
- Staff told us they felt involved and supported and worked well as a team.
- The provider had information governance arrangements.
There were areas where the provider could make improvements. They should:
- Take action to ensure the clinicians take into account the guidance provided by the Faculty of General Dental Practice when prescribing medicines.
- Improve the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment. In particular, ensuring use of rectangular collimation and following recent FGDP guidance when image quality rating.