Updated 5 November 2021
We carried out this announced inspection on 19 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 usually ask five key questions, however due to the ongoing pandemic and to reduce time spent on site, only the following three questions were asked:
• 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
CHDP Limited is in Surbiton in the London Borough of Kingston upon Thames and provides private dental care and treatment for adults and children.
There is ramp access to the practice for people who use wheelchairs and those with pushchairs.
The practice is located close to public transport links and car parking spaces are available near the practice.
The dental team includes five dentists, four hygienists, one dental nurse, two trainee dental nurses and a receptionist/practice manager. The practice has three 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 CHDP Limited is the principal dentist.
During the inspection we spoke with two dentists, one dental nurse and the receptionist/practice manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday and Thursday from 8am to 7.30pm
Tuesday and Wednesday from 9am to 6pm
Friday from 9am to 5.30pm
Saturday from 9am to 1pm
Sunday (Occasionally) from 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 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 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.
- The staff carried out some ‘highly recommended’ training as per the General Dental Council professional standards. Improvements were needed to the provider’s monitoring system to enable them to assure themselves that training was up-to-date and undertaken at the required intervals.
There were areas where the provider could make improvements. They should:
- Review the practice's procedures to ensure patient referrals to other dental or health care professionals were appropriately monitored to ensure they were received in a timely manner.
- Review the practice’s systems for assessing, monitoring and mitigating the various risks arising from the undertaking of the regulated activities. In particular risks relating to the handling and disposal of dental sharps, the risks around the use and storage of latex and the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002.
- Review the fire safety risk assessment and ensure that any actions required are complete and ongoing fire safety management is effective.