Deepdale Dental Health Center

We undertook a focused inspection of Deepdale Dental Health Centre on 12 March 2020. This inspection was carried out to review in detail the actions taken by the registered provider to improve the quality of care and to confirm that the practice was now meeting legal requirements.

The inspection was led by a CQC inspector who was supported by a specialist dental adviser.

We undertook a comprehensive inspection of Deepdale Dental Health Centre on 03 October 2019 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We found the registered provider was not providing well led care and was in breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can read our report of that inspection by selecting the 'all reports' link for Deepdale Dental Health Centre on our website www.cqc.org.uk.

As part of this inspection we asked:

• Is it well-led?

When one of the five questions are not met we require the service to make improvements and send us an action plan. We then inspect again after a reasonable interval, focusing on the area where improvement was required.

Our findings were:

We found this practice was providing well-led care in accordance with the relevant regulations.

The provider had made sufficient improvements to put right the shortfalls and had responded to the regulatory breach we found at our inspection on 03 October 2019.

Background

Deepdale Dental Health Centre is in Preston and provides NHS and private treatment for adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces, including spaces for blue badge holders, are available behind the practice.

The dental team includes six dentists, seven dental nurses, one dental hygiene therapist and two receptionists. The practice has six treatment rooms.

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 Deepdale Dental Health Centre is a senior partner.

During the inspection we spoke with five dentists, two dental nurses and the practice manager. The practice manager was supported by the lead nurse from their sister practice. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday – Friday 9.00 – 17.00

Our key findings were:

The provider had made improvements in relation to the regulatory breach we found at our inspection on 03 October 2019.

• Incidents that affected the health, safety and welfare of people using the service were now reported, reviewed and investigates. Staff had received training and information about incidents which could promote learning.
• There were systems in place to ensure the manual X-ray system was serviced and safety checks were performed routinely.
• The Hepatitis B immunity status was confirmed for all staff. Those staff who required a booster immunisation had received this. For any staff who had shown an immune response below that expected, there was a risk assessment in place which was focussed on minimizing the risk of injury from contaminated instruments and materials.
• The oversight of fire safety had improved.
• Radiography audits were in place which covered all dentists at the practice.
• Dental treatment records audits were in place, but the provider had failed to address the findings from these audits.

• The provider could not demonstrate that all clinicians followed guidance in respect to the completion of patient dental care records.
• Leadership and oversight of governance systems were improved.

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

• Take action to ensure the clinicians take into account the guidance provided by the Faculty of General Dental Practice when completing dental care records.

We carried out this announced inspection on 3 October 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.

Background

Deepdale Dental Centre is in the Deepdale area of Preston and provides NHS and some private dental treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces, including spaces for blue badge holders, are available behind the practice.

The dental team includes six dentists, seven dental nurses three of whom are trainees, one dental hygiene therapist and two receptionists. The practice has six treatment rooms.

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 Deepdale Dental Centre is the senior partner.

On the day of inspection, we collected seven CQC comment cards filled in by patients.

During the inspection we spoke with three dentists, two dental nurses, one receptionist and the practice management team. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

9.00 to 17.00 Monday to Friday

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 provider had systems to help them manage risk to patients and staff.
• The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• There were limited recording systems for incidents, accidents and near misses which occurred in the practice.
• The provider had thorough staff recruitment procedures.
• Not all 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 did not have effective leadership and culture of continuous improvement.
• Staff felt involved and supported 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 did not suitable information governance arrangements.

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 is not meeting are at the end of this report.

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

• Improve and develop the practice's current performance review systems and have an effective process established for the on-going assessment and supervision of all staff.