Updated 4 August 2021
We carried out this announced focused inspection on 9 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 specialist dental adviser.
As part of this inspection we 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
Kyrle Street Dental Practice is located close to Hereford County Hospital in Hereford and provides NHS and private dental care and treatment for adults and children. The services are provided under two Care Quality Commission registered providers at this location. This report only relates to the provision of general dental care provided by Kyrle Street Dental Practice. An additional report is available in respect of the general dental care services which are registered under Rodericks Dental Limited.
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 in a pay and display car park opposite the practice.
The dental team includes six dentists, eight qualified dental nurses (some of whom also undertake reception duties), three trainee dental nurses, one dental hygienist, two receptionists and a practice manager. The practice has seven treatment rooms.
The practice is owned by an 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 Kyrle Street Dental Practice is the practice manager.
During the inspection we spoke with three dentists, one dental nurse, the practice manager, a compliance manager and the company head of clinical compliance. 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 5pm.
Saturday and Sunday (for referred out of hours care) from 10am to 2pm.
Our key findings were:
- The practice was part of a corporate group which had a head office where support teams including human resources, health and safety, clinical support and patient support services were based. These teams supported and offered expert advice and updates to the practice when required.
- The practice was participating in the Dental Prototype Agreement Scheme. This scheme placed an increased emphasis on preventing future dental disease by providing preventive care treatments including fluoride varnish application, periodontal (gum) treatment and oral hygiene instruction. In addition to this patients were supported with self-care plans.
- Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
- 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. The practice had access to support from a dedicated human resources and recruitment team based within the company’s head office.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- The provider had effective leadership and a culture of continuous improvement.
- Staff felt involved and supported and worked as a team. There was an effective staffing structure which extended to senior management who were visible and supported the practice manager on the day of our visit by basing themselves at the practice.
- The provider had information governance arrangements.
There were areas where the provider could make improvements. They should:
- Take action to ensure that all clinical staff have adequate immunity for vaccine preventable infectious diseases.