Archived: Shiremoor Dental Practice

We carried out this announced focused inspection on 6 April 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 usually ask five key questions, however due to the ongoing COVID-19 pandemic and to reduce time spent on site, only the following three questions were 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:

• The dental clinic was visibly 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 needed to review their systems to help them manage risk to patients and staff.
• Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The practice needed to review their recruitment procedures to ensure they reflected current legislation.
• The clinical staff provided patients’ care and treatment in line with current guidelines; apart from in relation to conscious sedation.
• 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.
• The provider’s leadership and management systems required improvement.
• 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

Shiremoor Dental Practice is in North Tyneside and provides private dental care for adults and NHS dental care for children.

There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces are available on the driveway and near the practice.

The dental team includes two dentists, five dental nurses, one dental hygienist, three dental therapists and a practice manager. Reception duties are carried out by the dental nurses. The practice has two treatment rooms, both sited on the ground floor.

During the inspection we spoke with one dentist, two dental nurses, one dental therapist 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 8.45am to 6pm

Tuesday 8.45am to 7.30pm

Wednesday 8.45am to 8pm

Thursday 8.45am to 7.30pm

Friday 9am to 5pm

Occasional Saturdays 9am to 1pm.

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 the practice's processes for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken for all hazardous materials.
• Improve the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment. In particular, ensure all the relevant information is completed and available to staff within the radiation protection file.
• Improve the practice’s sharps procedures to ensure the practice is in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.