We carried out this announced focused inspection on 20 July 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.
To get to the heart of patients’ experiences of care and treatment, we asked the following three 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 not providing well-led care in accordance with the relevant regulations.
Background
Peacock and Shrestha is a well-established practice based in Norwich, that provides NHS treatment to about 15,000 patients. The dental team includes three dentists, two dental hygienists, a practice manger and six dental nurses. The practice has six treatment rooms, not all of which were operational at the time of our inspection.
There is portable ramp access to the practice for wheelchair users.
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 the practice is one of the partners.
The practice is open Monday to Fridays from 8am to 5pm.
During the inspection we spoke with three dentists, the practice manager, two dental nurses and reception staff. We looked at practice policies and procedures and other records about how the service is managed.
Our key findings were:
- The provider had infection control procedures which reflected published guidance.
- 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 dealt with complaints positively and efficiently.
- Dental care records did not always follow guidance provided by the Faculty of General Dental Practice.
- Hot water temperatures did not always reach the required temperatures to prevent legionella bacteria build up.
- There was a system for recording, investigating and reviewing incidents or significant events. However there was no evidence to show how learning from incidents and accidents was used to drive improvement and safety.
We identified regulations the provider was not complying with. They must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
Full details of the regulation the provider was not meeting are at the end of this report.
There were areas where the provider could make improvements. They should
- Take action to ensure dentists are aware of the guidelines issued by the British Endodontic Society for the use of rubber dam for root canal treatment.
- Improve the practice’s sharps procedures to ensure the practice is in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
- Implement a system to identify individual lost or missing prescriptions.
- Take action to ensure all clinicians are adequately supported by a trained member of the dental team when treating patients in a dental setting taking into account the guidance issued by the General Dental Council.
- Implement a system for monitoring and recording the fridge temperature to ensure that medicines and dental care products were stored in line with the manufacturer’s guidance.