Derby House Dental Practice

We undertook a follow up focused inspection of Derby House Dental Practice on 26 November 2019. This inspection was carried out to review in detail the actions taken by the registered provider to improve the quality of care and to confirm that the practice was now meeting legal requirements.

The inspection was led by a CQC inspector who was supported by a specialist dental adviser remotely.

We undertook a comprehensive inspection of Derby House Dental Practice on 5 September 2019 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We found the registered provider was not providing well led care and was in breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can read our report of that inspection by selecting the 'all reports' link for Derby House Dental Practice on our website www.cqc.org.uk.

As part of this inspection we asked:

• Is it well-led?

When one or more of the five questions are not met we require the service to make improvements and send us an action plan. We then inspect again after a reasonable interval, focusing on the area where improvement was required.

Our findings were:

Are services well-led?

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

The provider had made improvements in relation to the regulatory breach we found at our inspection on 5 September 2019.

Background

Derby House Dental Practice is in Derby city centre and provides NHS and private dental treatment to adults and children.

The dental team includes three dentists, four dental nurses including four trainees, one receptionist and a practice manager. The practice has three treatment rooms and an instrument decontamination room. One of the treatment rooms is located on the ground floor. There is level access into the practice for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice on local roads and car parks. There is parking space opposite the practice for blue badge holders and those with restricted mobility.

The practice is owned by an organisation and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. At the time of inspection there was no registered manager in post as required as a condition of registration. A registered manager is legally responsible for the delivery of services for which the practice is registered. The organisation informed us they had identified a manager who would be taking over management responsibilities at Derby House Dental Practice and would be put forward to be the registered manager.

The practice is open: Monday to Friday: from 8.30am to 5.30pm.

Our key findings were:

• Improvements had been made to infection prevention and control processes.
• The system for monitoring the security of NHS prescriptions had been reviewed and improvements made.
• The system for managing safer sharps had been reviewed and improved.
• Records relating to the Control of Substances Hazardous to Health (COSHH) regulations 2002 had been amended to include a risk assessment for each hazardous product.

We carried out this announced inspection on 5 September 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 not providing well-led care in accordance with the relevant regulations.

Background

Derby House Dental Practice is in Derby city centre and provides NHS and private dental treatment to adults and children.

The dental team includes three dentists, four dental nurses including four trainees, one receptionist and a practice manager. The practice has three treatment rooms and an instrument decontamination room. One of the treatment rooms is located on the ground floor. There is level access into the practice for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice on local roads and car parks. There is parking space opposite the practice for blue badge holders and those with restricted mobility.

The practice is owned by an organisation 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 Derby House Dental Practice is the practice manager.

On the day of inspection, we collected 14 CQC comment cards filled in by patients.

During the inspection we spoke with one dentist, one dental nurse, one receptionist, the practice manager and a manager from the provider’s organisation. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Friday: from 8.30am to 5.30pm.

Our key findings were:

• The practice appeared clean and well maintained.
• 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.
• Improvements could be made to the practice’s systems for managing sharp instruments.
• The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• Improvements were needed to the system for assessing materials and substances that are hazardous to health.
• The provider had thorough staff recruitment procedures.
• 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.
• Improvements were needed to the systems for ensuring the security of NHS prescription pads.
• Improvements to the way manual cleaning was completed at the practice could be made.
• The audit of infection prevention and control in the practice was not robust.
• Staff provided preventive care and supporting patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• The provider had 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 dealt with complaints positively and efficiently.
• The provider had suitable information governance arrangements.

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

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

Full details of the regulation the provider was not meeting are at the end of this report.