Twelve Dental

Updated 20 May 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

We inspected the The Academy of Birmingham Cosmetic Dentistry on 11 February 2016. The inspection team consisted of one CQC inspector and a dental specialist advisor.

Prior to the inspection we reviewed information we held about the provider from various sources. We informed Healthwatch that we were inspecting the practice and we did not receive any information of concern from them. We also requested details from the provider in advance of the inspection. This included their latest statement of purpose describing their values and objectives.

During the inspection we toured the premises, spoke with the practice manager, the principal dentist and the dental nurse. We reviewed CQC comment cards which patients had completed. We were unable to speak with patients on the day because the dentist had rescheduled all dental appointments to provide staff with ample time to speak with the inspection team. We reviewed a range of practice policies and practice protocols and other records relating to the management of the service.

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 caring?
• Is it responsive to people’s needs?
• Is it well-led?

These questions therefore formed the framework for the areas we looked at during the inspection.

Updated 20 May 2016

We carried out an announced comprehensive inspection on 11 February 2016 to ask the practice the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this practice was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this practice was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this practice was providing well-led care in accordance with the relevant regulations.

Background

The Academy of Birmingham Cosmetic Dentistry provides private dental care and treatment. The principal dentist operates the practice as a limited company and is the sole director and registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons 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 principal dentist is supported by a practice manager, one dental nurse and one receptionist. The receptionist had been on long term leave and was due to return to work the week after our visit. Another two dentists also visit the practice to provide additional dental services. One dentist visits on a fortnightly basis to provide dental implants and cosmetic orthodontic treatment. The other visits every six weeks and provides orthodontic treatment only.

The practice is located in the heart of the city centre. There is wheelchair access to the premises and the main treatment room is on the ground floor. The premises consist of a reception area, waiting room, one treatment room, a storage room and a decontamination room on the ground floor. There is a second treatment room, a storage room, a disused X-ray room and toilet facilities on the lower ground floor. Opening hours are 8.30am Monday – Wednesday, 9.30am to 6.30pm on Thursdays, 8.30am to 4pm on Fridays and 9am to 2.30pm on Saturdays.

Thirteen patients provided feedback about the practice. We looked at comment cards patients had completed prior to the inspection. Overall the information from patients was complimentary. Patients were positive about their experience and they commented that the practice provided a professional service that was of a high standard.

Our key findings were:

• Emergency equipment for dealing with medical emergencies mostly reflected published guidelines. We highlighted areas for improvement and these were all dealt with on the day of our visit.
• An infection control policy was in place and procedures followed mainly reflected published guidance. We highlighted areas for improvement and these were all dealt with promptly.
• The practice had systems to assess and manage risks to patients, including infection prevention and control, safeguarding and the management of medical emergencies.
• Patient feedback was positive and they found the staff friendly and professional.
• Patients commented that the practice was clean and safe.
• The appointment system met the needs of the patients and waiting times were kept to a minimum.
• The practice had a complaints process in place. No written complaints had been received by the practice in the last 12 months.
• Staff told us they felt well supported and comfortable to raise concerns or make suggestions.
• The practice demonstrated that they regularly undertook audits in infection control, radiography and dental care record keeping.
• We identified some shortfalls in areas such as radiation protection and staff recruitment and most of these were promptly resolved.

There were areas where the provider could make improvements and should:

• Review the practice’s protocols for the use of rubber dam for root canal treatment giving due regard to guidelines issued by the British Endodontic Society.
• Establish whether the practice is in compliance with its legal obligations under Ionising Radiation Regulations (IRR) 99 and Ionising Radiation (Medical Exposure) Regulation (IRMER) 2000.
• Review the protocol for completing accurate, complete and detailed records relating to employment of staff. This includes ensuring recruitment checks, including references, are suitably obtained and recorded.