Updated 13 July 2021
We carried out this announced inspection on 22 June 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.
As part of this inspection we 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:
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
Amblecote Dental Care is in Brierley Hill and provides NHS and private dental care and treatment for adults and children.
There is access via a ramp to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for people with disabilities, are available in the practice car park.
The dental team includes six dentists, 14 dental nurses, two dental hygienists, one dental hygiene therapists, two receptionists and one practice manager. The practice has five treatment rooms.
The practice is owned by a partnership 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 Amblecote Dental Care is the practice manager.
During the inspection we spoke with two dentists, four dental nurses, one dental hygiene therapist, two receptionists and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday from 8.30am to 7pm
Tuesday from 8.30am to 6pm
Wednesday from 8.30am to 8pm
Thursday from 8.45am to 6pm
Friday from 8.30am to 4.30pm
Saturday (one per month) - By appointment only
Our key findings were:
- The practice was part of a corporate group which had a head office where support teams including human resources, health and safety, clinical support and patient support services were based. These teams supported and offered expert advice and updates to the practice when required.
- The practice appeared to be visibly clean and well-maintained.
- The provider had infection control procedures which mostly reflected published guidance. We found that sterilisers were validated at the start of the session but not every cycle, this shortfall was rectified during the inspection.
- 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. However, we found shortfalls in the recording of justification and reporting on images in relation to the cone beam computed tomography (CBCT) images.
- 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 practice had access to support from a dedicated human resources and recruitment team based within the provider’s head office.
- The practice was taking part in the Dental Prototype Agreement Scheme. This scheme placed an increased emphasis on preventing future dental disease by providing preventive care treatments including fluoride varnish application, periodontal (gum) treatment and oral hygiene instruction. In addition to this patients were supported with self-care plans.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- 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 had information governance arrangements.
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 HPA-CRCE-010 Guidance on the Safe Use of Dental Cone Beam (Computed Tomography).
- Improve the practice’s infection control procedures and protocols 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, ensuring every autoclave cycle is tested to provide assurance that the sterilization process had been successful.