Updated 19 November 2021
We carried out this announced focussed inspection on 25 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 a specialist dental adviser.
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 was providing well-led care in accordance with the relevant regulations.
Background
Acomb Dental Practice is in Acomb, York and provides 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.
The dental team includes four dentists, six dental nurses (two of whom are trainees), two dental hygiene therapists and two receptionists. The team is supported by the practice manager. The practice has four 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 Acomb Dental Practice is the practice manager.
During the inspection we spoke with one dentist, two 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 team was supported during the inspection by the group compliance manager.
The practice is open: Monday – Friday 8am to 5pm.
Our key findings were:
- The practice appeared to be visibly clean and well-maintained.
- The provider had infection control procedures; improvements could be made to the instrument decontamination process to accurately reflect 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.
- 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.
- The infection prevention and control audit did not accurately represent processes in place.
- Referrals to other healthcare professionals could be clearer and more detailed.
- 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 dealt with complaints positively and efficiently.
- The provider had information governance arrangements.
There were areas where the provider could make improvements. They should:
- 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: refresher training and processes undertaken to ensure instrument decontamination procedures and protocols accurately reflect published guidance.
- Take action to ensure audits of infection prevention and control accurately represent the process in place to improve the quality of the service. Practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.
- Take action to enhance the level of detail recorded in dental care records to ensure referrals to other health care professionals are prescribed clearly.