Maycroft Dental Practice

carried out this announced focussed inspection on 3 August 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 remote 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 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

Maycroft Dental Practice is in Woking and provides NHS and private dental care and treatment for adults and children.

There is level access, through use of a removable ramp, 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, three dental nurses, one trainee dental nurse, three dental hygienists, one practice manager and two receptionists. The practice has five 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.

At the time of inspection there was no registered manager in post as required as a condition of registration. A registered manager is legally responsible for the delivery of services for which the practice is registered.

During the inspection we spoke with three dentists, two dental nurses, a trainee dental nurse, two receptionists, a company head of commercial improvement 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 8am to 5pm
• Tuesday 8am to 5pm
• Wednesday 8am to 6.30pm
• Thursday 8am to 5pm
• Friday 8am to 5pm
• Saturday 9am to 5pm

Our key findings were:

• The practice appeared to be visibly clean but did require refurbishment in places.
• 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. However, improvements should be made to the Control of Substances Hazardous to Health file.
• 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 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. However, there was currently no registered manager.
• 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.
• The provider had information governance arrangements.

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

• Improve the practice's processes for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken and the products are stored securely.

• Take action to ensure the regulated activities at Maycroft Dental Practice are managed by an individual who is registered as a manager.

• Take action to ensure the suitability of the premises and ensure all areas are fit for the purpose for which they are being used in particular work surfaces, walls and floors and the size of the decontamination room.