57 Friar Gate Dental Practice

We carried out this announced comprehensive inspection on 15 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. There was scope for improvement in ensuring it was well-maintained.
• The practice infection control procedures did not always reflect published guidance.
• Staff knowledge and confidence in how to deal with medical emergencies was not robust or effective. Appropriate medicines and life-saving equipment were not always available as identified in guidance.
• Systems to manage risks for patients, staff, equipment and the premises were not effective or established in practice procedures.
• Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
• Staff recruitment procedures reflected 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.
• Leadership was not effective. Systems to promote continuous improvement and monitoring of the service were not effective.
• Systems to monitor and encourage staff training and development were not in place.
• A system to gather and respond to staff and patients feedback about the services provided were not established.
• Complaints were dealt with positively and efficiently.
• The practice had information governance arrangements.

Background

57 Friar Gate Dental Practice is in Derby and provides private dental care and treatment for adults and children.

The building has a listed status and is accessed via a set of steps. As such it is not accessible people who use wheelchairs and those with pushchairs and provision cannot be made to improve access.

The dental team includes 1 dentist, 4 dental nurses, 1 trainee dental nurse, 1 dental therapist, 1 practice manager and 1 receptionist. The practice has 3 treatment rooms.

During the inspection we spoke with the dentist, 2 dental nurses and the trainee dental nurse, the dental therapist, the receptionist 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, Tuesday and Thursday from 8.30am to 6pm.

Wednesday and Friday from 8.30am to 1pm.

Full details of the regulation the provider was not meeting are at the end of this report.

We identified regulations the provider was not complying with. They must:

• Systems or processes must be established and operated effectively to ensure compliance with the requirements of the fundamental standards as set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There were areas where the provider could make improvements. They should:

• Take action to ensure audits of antimicrobial prescribing and infection prevention and control are undertaken at regular intervals to improve the quality of the service. Practice should also ensure that, where appropriate, audits have documented learning points, and the resulting improvements can be demonstrated.