Updated 11 October 2021
We carried out this announced focused inspection on 22 September 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 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 providing well-led care in accordance with the relevant regulations.
Background
Rodericks Mexborough Ltd is in Mexborough and provides NHS and private dental care and treatment for adults and children. The practice has an NHS contract to provide treatment under conscious sedation.
There is level access at the rear of the practice for people who use wheelchairs and those with pushchairs. The practice has a dedicated car park at the rear of the property.
The dental team includes seven dentists, five dental nurses (two of whom are trainees), two receptionists and a practice manager. Anaesthetists attend the practice to carry out sedation as required. The practice has five treatment rooms.
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 Rodericks Mexborough Ltd is the practice manager.
During the inspection we spoke with two dentists, three dental nurses including the sedation nurse, a receptionist, the practice manager and a compliance manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday 8.30am to 5.30pm
Tuesday 8.30am to 6.30pm
Wednesday 8.30am to 5.30pm
Thursday 8.30am to 5.30pm
Friday 8.30am to 5.30pm
Our key findings were:
- The practice appeared to be visibly clean, tidy and well-maintained.
- The provider had infection control procedures which reflected published guidance.
- The provider had implemented standard operating procedures in line with national guidance on COVID-19.
- 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. Systems could be improved to review equipment servicing and radiographic equipment settings.
- The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The provider had staff recruitment procedures which reflected current legislation.
- The clinical staff provided patients’ care and treatment in line with current guidelines. The documentation of this in dental care records could be improved.
- 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 provider had effective leadership and a culture of continuous improvement.
- Staff felt involved and supported and worked as a team.
- The provider asked staff and patients for feedback about the services they provided.
- The provider could improve the handling of complaints.
- The provider had information governance arrangements.
There were areas where the provider could make improvements. They should:
- Improve the practice's systems for checking and monitoring equipment taking into account relevant guidance and ensure that all equipment is well maintained. In particular, compressor servicing and radiographic equipment settings.
- Improve the practice's complaint handling procedures and establish an accessible system for identifying, receiving, recording, handling and responding to complaints by service users.
- Take action to ensure the clinicians take into account the guidance provided by the Faculty of General Dental Practice when completing dental care records, and audit these effectively.