Dental Care Clinic Limited - Loughborough Road

We carried out this announced inspection on 08 July 2019 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 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 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:

Are services safe?

We found that this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this practice was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this practice was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this practice was providing well-led care in accordance with the relevant regulations.

Background

The practice is in the city of Leicester and provides NHS and private treatment to adults and children. The practice provides general dentistry services.

There is level access for people who use wheelchairs and those with pushchairs. There are no car parking facilities. Public car parking spaces, including some for blue badge holders, are available on side streets within close proximity of the practice.

The dental team includes four dentists, four dental nurses, one receptionist and a practice manager. The practice has three treatment rooms, two are on ground floor level. There is a separate decontamination facility.

The practice is owned by a company and as a condition of registration must have a person registered with the Care Quality Commission 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 Dental care Clinic Ltd – Loughborough Road is one of the dentists.

On the day of inspection, we collected 47 CQC comment cards filled in by patients.

During the inspection we spoke with two dentists, two dental nurses, the receptionist and the practice manager. We looked at practice policies and procedures, patient feedback and other records about how the service is managed.

The practice is open: Monday to Thursday from 9am to 6pm and Friday from 9am to 5pm. The practice closes during lunchtimes between 1pm to 2pm.

Our key findings were:

• The practice appeared clean and well maintained.
• The provider had infection control procedures which reflected published guidance. We noted some exceptions in relation to guidance being followed. Systems were strengthened following our inspection.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were mostly available, although we noted liquid glucose, a child self-inflating bag with reservoir and clear face masks sizes 0 to 4 were missing. These were obtained immediately after our inspection.
• The provider had most systems to help them manage risk to patients and staff. We noted some areas for improvement at the point of our inspection, for example, ensuring that all risks arising from legionella were suitably managed.
• The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The provider had staff recruitment procedures; however, references from previous employers were not held for two members of the team.
• The clinical staff provided patients’ care and treatment in line with current guidelines. We found that further detail was required in some aspects of record keeping.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• Staff provided preventive care and supporting patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• The provider had mostly effective leadership and culture of continuous improvement.
• Staff felt involved and supported and worked well as a team.
• The provider asked staff and patients for feedback about the services they provided.
• The provider had systems and processes to investigate, respond to and manage complaints.
• The provider had suitable information governance arrangements.

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

• Review the practice’s arrangements for ensuring good governance and leadership are sustained in the longer term.
• Review the practice's risk management systems for monitoring and mitigating the various risks arising from the undertaking of the regulated activities.

• Review the practice’s system for recording, investigating and reviewing incidents with a view to preventing further occurrences and ensuring that improvements are made as a result.
• Review the practice's recruitment procedures to ensure that appropriate checks are completed prior to new staff commencing employment at the practice.
• Review the practice’s arrangements for receiving and responding to patient safety alerts, recalls and rapid response reports issued by the Medicines and Healthcare products Regulatory Agency, the Central Alerting System and other relevant bodies, such as Public Health England and ensure that alerts are shared amongst the dental team.
• Review the practice's protocols for completion of dental care records taking into account the guidance provided by the Faculty of General Dental Practice.