Updated 11 December 2023
We carried out this announced comprehensive inspection on 21 November 2023 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 practice 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 advisor.
To get to the heart of patients’ experiences of care and treatment, we always ask the following 5 questions:
- Is it safe?
- Is it effective?
- Is it caring?
- Is it responsive to people’s needs?
- Is it well-led?
These questions form the framework for the areas we look at during the inspection.
Our findings were:
- The dental clinic appeared clean and well-maintained.
- The practice had infection control procedures which reflected published guidance.
- Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
- The practice had some systems to manage risks for patients, staff, equipment and the premises.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The practice had staff recruitment procedures which did not always reflect current legislation.
- Clinical staff provided patients’ care and treatment in line with current guidelines.
- Patients were treated with dignity and respect. Staff took care to protect patients’ privacy and personal information.
- Staff provided preventive care and supported patients to ensure better oral health.
- The appointment system worked efficiently to respond to patients’ needs.
- The frequency of appointments was agreed between the dentist and the patient, giving due regard to National Institute of Health and Care Excellence (NICE) guidelines.
- There was effective leadership and a culture of continuous improvement.
- Staff felt involved, supported and worked as a team.
- Staff and patients were asked for feedback about the services provided.
- Complaints were dealt with positively and efficiently.
- The practice had some information governance arrangements.
Background
Smilemakers is in Southampton and provides private and NHS dental care and treatment for adults and children.
There is step free access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for disabled people, are available at the practice. The practice has made reasonable adjustments to support patients with access requirements.
The dental team includes 6 dentists, 8 qualified dental nurses, 1 trainee dental nurse, 4 dental hygienists, 1 treatment co – ordinator, 3 practice managers, 6 receptionists and 1 content creator. The practice has 11 treatment rooms.
During the inspection we spoke with 2 dentists, 3 dental nurses and the practice manager. We looked at practice policies, procedures and other records to assess how the service is managed.
The practice is open:
Monday 8.30am - 7.30pm
Tuesday 8.30am - 5.30pm
Wednesday 8.30am - 7.30pm
Thursday 8.30am - 5.30pm
Friday 8.30am to 5.30pm
Saturday 9am – 2pm, twice a month
There were areas where the provider could make improvements. They should:
- Improve the practice's systems for assessing, monitoring and mitigating the various risks arising from the undertaking of the regulated activities. In particular, Legionella, fire and control of substances hazardous to health.
- Improve the practice's systems for checking and monitoring equipment taking into account relevant guidance and ensure that all equipment is well maintained.
- Ensure all staff have received training in Sepsis and to an appropriate level, in the safeguarding of children and vulnerable adults.
- Implement protocols for the use of closed circuit television cameras taking into account the guidelines published by the Information Commissioner's Office.