Updated 16 December 2021
We carried out this announced focussed inspection on 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 always ask the following five 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
Cromer House Dental Practice is located in Huyton, Liverpool and provides NHS and private dental care and treatment for adults and children.
There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for people with disabilities, are available near the practice in a multi-storey care park.
The dental team includes seven dentists, nine dental nurses, two of whom are trainees, a dental technician, and two receptionists, one of whom is also a treatment co-ordinator. The practice is led by the Clinical Director, who is also a dentist, a group practice manager, who in turn is supported by two compliance managers. The practice has seven 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 Cromer House Dental Practice is the group practice manager.
During the inspection we spoke with the practice Clinical Director, two dentists, two qualified dental nurses and one trainee nurse, two compliance managers and the group practice manager. We spoke briefly to the receptionists. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open: The practice is open from Monday to Friday, from 9am to 6pm.
Our key findings were:
- The practice appeared to be visibly 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. Some checks that were due had not taken place; we noted that contractors to undertake these checks had been booked.
- 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. Staff recruitment documents for all staff were not available, as required.
- 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.
- Staff provided preventive care and supported patients to ensure better oral health.
- The appointment system took account of patients’ needs.
- The provider had visible leadership and a culture of continuous improvement. Systems to oversee staff training and development could be strengthened.
- Staff felt involved and supported and worked as a team.
- The provider dealt with complaints positively and efficiently.
- The provider had information governance arrangements.
There were areas where the provider could make improvements. They should:
- Implement an effective recruitment procedure to ensure that appropriate checks are completed prior to new staff commencing employment at the practice and that all required checks have been conducted including adequate immunity for vaccine preventable infectious diseases.
- Improve the practice's risk management systems for monitoring and mitigating the various risks arising from the undertaking of the regulated activities.
- Improve and develop the practice's current performance review systems and establish effective processes for the on-going assessment and supervision of all staff.