Updated 29 February 2024
We carried out this announced comprehensive inspection on 23 January 2024 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 advisor.
To get to the heart of patients’ experiences of care and treatment, we always ask the following 5 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 clean and well-maintained.
- The practice had infection control procedures which reflected published guidance.
- Not all staff had received training to manage medical emergencies.
- Appropriate medicines and life-saving equipment were not always available. The practice took immediate action to replace missing items.
- The practice had systems to manage risks for patients, staff, equipment and the premises. We found shortfalls in the systems to manage risks within the premises. These included staff training, sharps safety and radiography. The practice took immediate action to mitigate these risks.
- 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.
- Clinical staff provided patients’ care and treatment in line with current guidelines.
- Patients were treated with dignity and respect. Staff took care to protect patients’ privacy and personal information.
- Staff provided preventive care and supported patients to ensure better oral health.
- The appointment system worked efficiently to respond to patients’ needs.
- The frequency of appointments was agreed between the dentist and the patient, giving due regard to National Institute of Health and Care Excellence (NICE) guidelines.
- There was effective leadership and a culture of continuous improvement.
- Staff felt involved, 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 practice had information governance arrangements.
Background
Theydon Dental Surgery is in Theydon Bois, Essex and provides private dental care and treatment for adults and children.
There is step free 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 access requirements.
The dental team includes 2 dentists, 2 trainee dental nurses, 1 dental hygienist, 1 dental therapist and 1 receptionist. The practice has 2 treatment rooms.
During the inspection we spoke with 1 dentist, 1 dental nurse and the receptionist. We looked at practice policies, procedures and other records to assess how the service is managed.
The practice is open:
Monday from 8.30am to 5.30pm.
Tuesday, Wednesday, Thursday and Friday from 8.30am to 3pm.
There were areas where the provider could make improvements. They should;
- Improve the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment.
- Develop systems to ensure an effective process is established for the on-going assessment, supervision and appraisal of all staff. Including the training, learning and development needs of individual staff members at appropriate intervals. In addition, ensure staff have received training to manage medical emergencies taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.
- Take action to ensure the suitability of the premises and ensure all areas are fit for the purpose for which they are being used. In particular, ensure any risks and actions highlighted in the Legionella risk assessment and fire risk assessment reports have been mitigated and the premises are safe for use.