Updated 18 August 2021
We carried out this announced focussed inspection on 20 July 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 remote 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 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
The Rodney Dental Practice is in Cheltenham and provides NHS and private dental care and treatment for adults and children.
There is stepped access to the practice. People who use wheelchairs were directed to other practices. 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 trainee dental nurses, a decontamination technician, a dental hygienist, three receptionists and a practice manager. The practice has five 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 Rodney Dental Practice is the principal dentist.
During the inspection we spoke with three dentists, three dental nurses, a trainee dental nurse, a dental hygienist, two receptionists 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 8.30am to 5pm
- Tuesday 8.30am to 5pm
- Wednesday 8.30am to 5pm
- Thursday 8.30am to 5pm
- Friday 8.30am to 5pm
Our key findings were:
- The practice appeared to be visibly clean and well-maintained.
- The provider had infection control procedures which reflected published guidance. However, the legionella checking processes were based on an externally provided risk assessment from 2012 and confirmation should be considered to confirm that it was still valid and in line with 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. However, improvements should be made to the Control of Substances Hazardous to Health file.
- 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.
- 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. However, there was no supporting policy for the operation of the closed-circuit television system.
There were areas where the provider could make improvements. They should:
- Improve the practice's processes for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken and the products are stored securely.
- Take action to implement any recommendations in the practice's Legionella risk assessment, 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 to ensure that the externally provided 2012 document is still valid and in line with guidance.
- Implement protocols for the use of closed-circuit television cameras taking into account the guidelines published by the Information Commissioner's Office.