Updated 22 June 2022
We carried out this announced focused inspection on 17 May 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 specialist dental adviser.
To get to the heart of patients’ experiences of care and treatment, we usually ask five key questions, however due to the ongoing COVID-19 pandemic and to reduce time spent on site, only the following three questions were 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:
- The dental clinic was visibly clean and well-maintained.
- The practice had infection control procedures which reflected published guidance. However, staff were not recording water temperatures in line with Legionella risk assessment recommendations. The provider said they would address this moving forward.
- Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were mostly available. The provider ordered the missing item immediately.
- 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.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- 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.
- 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 69 practices and this report is about 103a Golden Hillock Road.
Bhandal Dental Practice, 103a Golden Hillock Road is in Small Heath, Birmingham 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 disabled people, are available near the practice. The practice has made reasonable adjustments to support patients with additional needs.
The dental team includes four dentists (including two specialist dentists), three dental nurses (including two trainees), one orthodontic therapist, two practice management staff and one receptionist. The practice has three treatment rooms.
During the inspection we spoke with one dentist, one dental nurse and the practice manager. A Registered Manager from another Bhandal Dental Practice attended to provide support during this inspection. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday to Friday from 9am to 6pm. The practice is closed each day between 1pm to 2pm.
The practice is also currently open on Saturday from 9am to 1pm.
The practice had taken steps to improve environmental sustainability. For example, staff turn off lights and equipment, as appropriate when not in use. Staff are encouraged to recycle as much as possible.
There were areas where the provider could make improvements. They should:
- Take action to implement any recommendations in the practice's Legionella risk assessment, taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.’ In particular staff were logging that they had checked both hot and cold-water temperatures but were not recording the actual temperature of the water for audit purposes.
- Implement an effective system of checks of medical emergency equipment and medicines taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.