CQC Hotspots – September 2016


Reading through a further sample of 53 CQC dental inspections undertaken in various parts of England during September, highlighted a number of breaches which can easily be avoided.

Of the 53 practices sampled, only one was issued with breach notifications which is a great performance overall. Shortcomings were again found mainly across the “Well Led” sections.

n the spirit of continuous improvement and to try and help 100% of practices achieve a clean pass, here are some of the key-findings which might just keep another practice out of trouble.

Once again, always remember that if something is not recorded or evidenced, in the eyes of the CQC and other external bodies such as the NHS, it didn’t happen, even though you may know full well that it did! This continues to catch practices out leading to frustration and avoidable stress for all!


  • Management roles and responsibilities not clearly defined leading to confusion for patients and the team. Always make sure you have job profiles in place and that everyone is aware of areas of responsibility/authority.
  • Recruitment checks and procedures including evidence and records.
  • Equipment testing/servicing records. A robust reminder system should be in place to ensure actioned on time. Don’t rely on suppliers contacting you, responsibility remains with the practice.
  • Follow-up actions from patient complaints & feedback. Not enough just to log complaints, lessons must be learned and changes made where necessary. Record action taken and evidence that it is shared with the team e.g. team meeting minutes or notices.
  • Team meetings should be held regularly (more than once or twice a year and usually at least monthly) to keep everyone up to date and include lessons learned from audits/patient feedback. Remember your meeting minutes to evidence content.
  • All audits must show evidence of learning and action points.
  • The team must be encouraged to report any concerns over quality of procedures, equipment, patient care and safety. This is everyone’s responsibility under Health & Safety at Work regulations and guidelines from all regulatory bodies including CQC, NHS and GDC. All discussions must be actioned and followed-up with evidence.
  • Significant Incident records must be maintained and recorded, including follow-up actions and discussions. Make sure the team are aware of your procedures.
  • Audits and checks must be undertaken regularly and consistently. A robust diary system should be in place to ensure they are not missed and that the next audit date can be quickly evidenced/identified.

Robust diary management and task reminders are often the solution to highlighted issues. Think about what would happen if you went off work for a month from tomorrow – who would pick up your responsibilities and how would they know what needed to be done and when?

Findings from previous inspection reviews can be found here:  CQC Hotspots

There is plenty of help out there to plug any management gaps including Your Dental Manager, so please do get in touch if you have any concerns or want to further improve the overall management/efficiency of your practice:info@yourdentalmanager.co.uk

CQC Hotspots – September 2016

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