CQC Hotspots – October 2016

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Reviewing a further sample of 24 CQC dental inspection reports published in October, highlighted a number of breaches which can easily be avoided.

Of the 24 practices sampled, 7 practices were issued with breach notifications which is significantly higher than previous samples undertaken. Shortcomings were again found mainly across the “Well Led” and “Safe” criteria.

We are starting to see more practices picked up for out of date policies, procedures, audits and check-lists. Always important to keep on top of all the good work done in the past and keep everything up to date.

In 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.

  • Effectiveness of policies and procedures is featuring strongly. Make sure that you don’t rely on “out of the box templates”. These are very useful but must be tailored/personalised to your practice and reflect what actually happens on a day to day basis. Always share with the team and ensure everyone knows what your policies/procedures are. Don’t leave them “in the box”.
  • Policies and procedures are not always kept up to date, regularly reviewed, updated and shared across the team.
  • Out of date risk assessments and critical audits including 6 monthly Infection control and radiography checks.
  • Inadequate recruitment checks and procedures including right to work, references and qualification checks. Make sure your staff files are well organised and compliant.
  • Missing or incomplete staff appraisals, personal development plans and training records.
  • COSHH records and fact-sheets not being completed, or updated, as different products/materials are introduced into the practice.
  • No Business Continuity plan – unexpected events happen and you need to be prepared as a practice.
  • Inadequate or missing safeguarding training for children and vulnerable adults – dreamstime_xs_43893109always make sure the team know how and where to raise concerns.
  • Out of date portable appliance and gas safety checks pose a risk to the practice and your patients.
  • Legionella reports left in the drawer with recommendations not fully implemented, particularly the recording of regular temperature checks for taps.
  • Inadequate Medical Emergency kit/supplies. Make sure you comply with the Resuscitation Council and GDC guidelines.
  • Missing or inadequate sharps/stick injury policies and procedures to follow in the event of an incident.
  • Not seeking or reacting to patient feedback. Make sure you have comment forms and collection box easily accessible to patients. Don’t forget to review and action the contents.
  • Irregular, or no, team meetings.  Make sure you hold meetings more than once or twice a year (preferably monthly), to keep everyone up to date and include lessons learned from audits/patient feedback. Remember to keep meeting minutes to evidence discussions.
  • Missing/out of date audits and checks. 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.
  • Audits without essential evidence of learning and action points.
  • Missing or inadequate reporting of significant incident records, including follow-up actions and discussions. Make sure the team are aware of your procedures.
  • No evidence of tracking, monitoring and reacting to patient safety reports, including CAS and MHRA.
  • The Duty of Candour requirement is often asked of staff during inspections. Make sure that candour is understood by all the team and that the procedures/working environment is in place to encourage.

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!

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 – October 2016

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