Updated 24 April 2019
We carried out this announced inspection on 21 March 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 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 providing well-led care in accordance with the relevant regulations.
Background
The practice is in Loughborough, a town in the Charnwood borough of Leicestershire; it is close to the Nottinghamshire border. It provides private treatment to mostly adults and some children.
There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available in the practice’s car park.
The dental team includes four dentists, two dental surgeons, one anaesthetist, one dental hygienist, five dental nurses and a practice manager. Dental nurses share receptionist duties.
The practice has three treatment rooms; all on ground floor level. There is a separate decontamination facility.
Services provided include general dentistry, cosmetic dentistry, endodontics, orthodontics, implants and sedation.
The provider operates three practices under the brand name in Leicester, Loughborough and Nottingham.
The practice is owned by a company and as a condition of registration must have a person registered with the Care Quality Commission 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 Dental Suite (Loughborough) Limited is one of the principal dentists.
On the day of inspection, we collected 33 CQC comment cards filled in by patients.
During the inspection we spoke with two dentists (including one of the principals), three dental nurses, the dental hygienist, the practice manager and a compliance adviser. We looked at practice policies and procedures, patient feedback and other records about how the service is managed.
The practice is open: Monday to Wednesday from 8.30am to 5.30pm, Thursday from 8am to 6pm and Friday from 8.30am to 5pm.
Our key findings were:
- The practice appeared clean and well maintained.
- 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 practice had systems to help them manage risk to patients and staff.
- The provider had suitable safeguarding processes, although one staff member had not completed training to the recommended level at the time of our visit. This was completed and evidence sent to us afterwards. Staff showed awareness of their responsibilities for safeguarding vulnerable adults and children.
- The provider had staff recruitment procedures; we noted these could be strengthened to ensure all staff had a Disclosure and Barring Service check at the point of their recruitment.
- 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 were providing preventive care and supporting patients to ensure better oral health.
- The appointment system met patients’ needs.
- The provider had effective leadership and culture of continuous improvement.
- Staff felt involved 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.
There were areas where the provider could make improvements. They should:
- Review the practice’s processes for reporting RIDDOR incidents (Reporting of Injuries, diseases and Dangerous Occurrences) and ensure that appropriate notification is made when required.
- Review staff training to ensure that all the staff have received training, to an appropriate level, in the safeguarding of children and vulnerable adults.
- Review the practice's recruitment procedures to ensure that appropriate checks are completed prior to new staff commencing employment at the practice.
- Review staff awareness of Gillick competency and the requirements of the Mental Capacity Act 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.