The Evergreen Dental Centre

We carried out this announced focused inspection on 14 October 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 two specialist dental advisers

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 not providing well-led care in accordance with the relevant regulations.

Background

The Evergreen Dental Centre is in Reading and provides private dental care and treatment for adults and children.

There is step free access to the practice, via a ramp for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for disabled people, are available at the practice.

The dental team includes four dentists, two dental nurses, one dental hygienist, one receptionist and a practice manager. The practice has two 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 the practice is the principal dentist.

On the day of inspection, the practice was closed to patients.

During the inspection we spoke with two dentists, one dental nurse, one receptionist 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 to Thursday 9am – 6pm
• Friday 9am to 5pm
• Alternate Saturdays 9am to 1pm

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.
• 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, but improvements were needed.
• 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 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.

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

• Improve the practice's recruitment procedures to ensure accurate, complete and detailed records are maintained for all staff.

Full details of the regulations the provider was not meeting is at the end of this report.

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

• Review the practice’s audit protocols to ensure, that where appropriate audits have documented learning points and the resulting improvements can be demonstrated in a timely way.
  
• Implement effective audits for prescribing of antibiotic medicines taking into account the guidance provided by the Faculty of General Dental Practice.