The Victoria Buildings

We carried out this announced focused inspection on 27 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.
• Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Staff provided preventive care and supported patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• There was effective leadership and a culture of continuous improvement.
• Staff felt involved and supported and worked as a team.
• Staff and patients were asked for feedback about the services provided.
• The dental clinic had information governance arrangements.
• The provider had staff recruitment procedures which reflected current legislation. However, improvements were needed to ensure important checks were carried out at the time of recruitment.
• The practice had systems to help them manage risk to patients and staff. However improvements were needed in relation to the ongoing fire monitoring protocols.
• Improvements were needed to ensure all equipment was serviced and maintained in accordance with manufacturer’s guidelines.

Background

The provider has two practices and this report is about The Victoria Buildings.

The practice is in Newcastle Upon Tyne and provides NHS and private dental care and treatment for adults and children.

There is access to the practice via a ramp for people who use wheelchairs and those with pushchairs. The practice is located close to local transport routes and car parking spaces are available at the practice. The provider has made reasonable adjustments to support patients with additional needs; for example the availability of a hearing induction loop and an accessible toilet.

The dental team includes three dentists, one dental specialist, six dental nurses, one trainee dental nurse, one dental hygienist, one receptionist and the practice manager. The practice has three treatment rooms.

During the inspection we spoke with two dentists, one dental nurse, one dental hygienist, a compliance manager and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Mondays from 9.00am to 5.00pm

Tuesdays, Thursdays and Fridays from 9.00am to 5.30pm

Wednesdays from 9.00am to 6.00pm

Lunch (everyday) from 1.00pm to 2.00 pm

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

• 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.
• Implement an effective recruitment procedure to ensure that appropriate checks are completed prior to new staff commencing employment at the practice including ensuring that all clinical staff have adequate immunity for vaccine preventable infectious diseases.
• Implement protocols and procedures to ensure staff are up to date with their mandatory training and their continuing professional development.
• Improve the practice's systems for checking and monitoring equipment taking into account relevant guidance and ensure that all equipment is well maintained. In particular in relation to the suction motor.
• Take action to ensure the practice’s ongoing fire safety management is effective.
• Implement a system to ensure patient referrals to other dental or health care professionals are centrally monitored to ensure they are received in a timely manner and tracked.