Archived: Toothpassion Ltd

We carried out this announced focussed inspection 30 November 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 not 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

Toothpassion Ltd is in Leeds city centre and provides private dental care and treatment for adults and children.

The practice has two treatment rooms which are both located on the first floor. City centre car parking spaces, including dedicated parking for people with disabilities, are available near the practice.

The dental team includes four dentists, one dental nurse and a receptionist.

The practice is owned by a company 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 Toothpassion Ltd is the principal dentist.

During the inspection we spoke with the principal dentist, the dental nurse and the receptionist. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Thursday: 9am to 5:30pm

Our key findings were:

• The provider had infection control procedures, these needed to be reviewed and improvements made, particularly in respect of manual cleaning.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available. However, medical emergencies training, including basic life support was overdue for all staff.
• The provider’s systems to help them manage risk to patients and staff needed to be reviewed.
• The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The risks associated with Legionella were not effectively monitored and assessed.
• The provider had staff recruitment procedures which reflected current legislation.
• 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.
• The risks associated with the control of substances hazardous to health should be better identified and assessed.
• Staff provided preventive care and supported patients to ensure better oral health.
• Improvements should be made to the quality assurance systems to ensure effective leadership and a culture of continuous improvement.
• Improvements should be made to the quality assurance systems, particularly in relation to audit cycles within the practice.
• Staff felt involved and supported and worked as a team.
• Improvements should be made to staff knowledge and understanding of the Mental Capacity Act (2005) and how it relates to dentistry.

We identified regulations the provider was not complying with. They must:

• Ensure care and treatment is provided in a safe way to patients.

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

• Improve the practice's processes for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken and the products are stored securely.

• Improve and develop staff awareness of 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.

• Take action to ensure audits of antimicrobial prescribing and dental care records are undertaken at regular intervals to improve the quality of the service. Practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.