Denbeigh House Dental Clinic

 We carried out this announced comprehensive inspection on 27 June 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 and well-maintained.

• The practice did not have infection control procedures which reflected published guidance.
• Staff knew how to deal with medical emergencies. Not all the appropriate medicines and life-saving equipment were available.
• The practice systems to help them manage risk to patients and staff were not robust or effective. Specifically, staff recruitment, equipment and the premises.
• Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children. 
• Staff recruitment procedures did not reflect 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.
• Effective leadership and a culture of continuous improvement was not in place.
• Staff felt involved, supported and worked as a team.
• Staff were asked for feedback about the services provided.
• Overall improvements were needed to ensure governance systems and arrangements were in place.

Background 

Denbeigh House Dental Surgery is in Birmingham and provides NHS and private dental care and treatment for adults and children. 

There is step free access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for disabled people, are available near the practice. The practice has made reasonable adjustments to support patients with access requirements.

The dental team includes 6 dentists, 6 dental nurses, 1 dental therapist, 1 practice manager and 2 receptionists. The practice has 6 treatment rooms. 

During the inspection we spoke with 1 dentist, 2 dental nurses and 1 receptionist. We also spoke to an external compliance consultant. We looked at practice policies, procedures and other records to assess how the service is managed. 

The practice is open: Monday to Friday from 8.30am to 5.30pm 

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

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

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

• 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.
• Implement protocols for the use of closed circuit television cameras taking into account the guidelines published by the Information Commissioner's Office.