Updated 17 January 2023
We carried out this announced comprehensive inspection on 16 November 2022 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 adviser.
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 was visibly clean.
- 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 systems to help them manage risk to patients and staff were not working effectively. These include the risks associated with fire, hazardous substances and the use of radiation.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The practice had staff recruitment procedures which reflected current legislation. Improvements could be made to these processes.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Patients were treated with dignity and respect and staff 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.
- Staff felt involved and 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 dental clinic had information governance arrangements.
Background
Excel Dental Centre is in Cheadle and provides NHS and private dental care and treatment for adults and children. The service also offers dental implants and treatments under conscious sedation.
There is level access to the practice for people who use wheelchairs and those with pushchairs. However, toilet facilities are not on the ground floor. Patients are made aware of this. Car parking spaces are available near the practice.
The dental team includes 3 dentists, 1 visiting implantologist, 1 visiting seditionist, 1 qualified dental nurse, 3 trainee dental nurses, 3 dental hygienists, 2 receptionists (one of who is also a qualified dental nurse) and a practice manager. The practice has 3 treatment rooms.
During the inspection we spoke with 2 dentists, 1 dental nurse 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 to Friday from 8:30am to 5:30pm
We identified regulations the provider was not complying with. They must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Full details of the regulation the provider was not meeting is at the end of this report.
There were areas where the provider could make improvements. They should:
- Improve and develop staff awareness of the requirements of the Mental Capacity Act 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.
- Take action to ensure clinicians record in the patients’ dental care records or elsewhere the reason for taking X-rays, a report on the findings and the quality of the image in compliance with Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment.