Updated 31 October 2022
We carried out this announced comprehensive inspection on 12 October 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 practice 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 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:
- The dental clinic appeared to be visibly clean and well-maintained.
- The practice had infection control procedures which reflected published guidance.
- Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
- The practice had systems to help them manage risk to patients and staff.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The practice had staff recruitment procedures which reflected current legislation. Evidence of immunity was not obtained for all clinical staff.
- The clinical staff provided patients’ care and treatment in line with current guidelines. Systems to document care consistently and audit this could be improved.
- Patients were treated with dignity and respect and staff 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 system to track referrals to other providers could be improved.
- There was effective leadership and a culture of continuous improvement.
- Staff felt involved and supported and worked as a team.
- Staff and patients were asked for feedback about the services provided.
- Complaints were dealt with positively and efficiently.
- The dental clinic had information governance arrangements.
Background
The provider has 15 practices and this report is about The Dental Surgery Leeds.
The Dental Surgery Leeds is in Leeds 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 3 dentists, 3 dental nurses, a practice manager and 1 receptionist. The practice has 3 treatment rooms.
During the inspection we spoke with the company owner, 2 dentists, 2 dental nurses, the receptionist, the practice manager and the company group manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday to Thursday 9am to 5.30pm
Friday 9am to 5pm
There were areas where the provider could make improvements. They should:
- Take action to ensure audits are effective in improving the quality of the service. The practice should ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.
- Take action to ensure that all clinical staff have adequate immunity for vaccine preventable infectious diseases.
- Implement a system to ensure all patient referrals to other dental or health care professionals are centrally monitored to ensure they are received in a timely manner and not lost.