8 November 2017
During a routine inspection
We carried out this announced inspection on 8 November 2017 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 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 five 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:
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
Luton Dental Centre is in Bedfordshire and provides NHS and private treatment to patients of all ages.
There is ramp access through the rear of the building for people who use wheelchairs and pushchairs. Car parking spaces are available a short walk from the practice.
The dental team includes 13 dentists, 13 dental nurses (of which six are trainees) one dental hygienist, one dental hygienist therapist, nine receptionists, a practice manager and a cover manager. The practice has 11 treatment rooms.
The practice is owned by a company and as a condition of registration must have a person registered with the Care Quality Commission 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 Luton Dental Centre was the provider.
On the day of inspection we collected 25 CQC comment cards filled in by patients. This information gave us a positive view of the practice.
During the inspection we spoke with six dentists, five dental nurses, 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 from 8am to 5.30pm
Tuesday from 8am to 7pm
Wednesday from 8am to 7pm
Thursday from 8am to 5.30pm
Friday from 8am to 5.30pm
Saturday from 8.30am to 1pm
Our key findings were:
- The practice was clean and well maintained.
- The practice had infection control procedures which mostly reflected published guidance.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- The practice had systems to help them manage risk.
- The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
- Staff recruitment procedures were in line with regulation. There was scope to improve the organisation of recruitment documents in order that full oversight of these was maintained.
- 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.
- The appointment system met patients’ needs.
- The practice had effective leadership. Staff felt involved and supported and worked well as a team.
- The practice asked staff and patients for feedback about the services they provided.
- The practice dealt with complaints positively and efficiently.
There were areas where the provider could make improvements. They should:
- Review the practice’s infection control procedures and protocols to take into account guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and have regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’.
- Review the practice's recruitment policy and procedures to ensure accurate, complete and detailed records are maintained for all staff.
- Review the practice’s protocols for ensuring that all clinical staff have adequate immunity for vaccine preventable infectious diseases.
- Review the protocols and procedures to ensure staff are up to date with their mandatory training and their Continuing Professional Development (CPD).