CQC Hotspots – November 2016


Reviewing a further sample of 50 CQC dental inspection reports published in November, highlighted a number of breaches which can easily be avoided.

Shortcomings were spread across the “Safe”, “Effective” and “Well Led” criteria. Recruitment procedures continue to feature prominently as does knowledge of the Mental Capacity Act 2005 and it’s impact on valid consent.

Of the 50 practices sampled, just 4 practices were issued with breach notifications. Clearly the vast majority of practices are getting things right, which is great news.

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 from these very recent inspections, which might just keep another practice out of trouble.

  • Regularly share your policies & procedures with the team and ensure everyone knows where they can be found. Don’t leave them “on the shelf”.
  • Keep your policies and procedures up to date with regular reviews and always date the review as evidence. Any changes/updates must be communicated to the team.
  • Inadequate recruitment checks and procedures including right to work, references and qualification checks continue to feature regularly. Make sure your staff files are well organised and compliant. Use checklists to ensure everything is covered and evidenced.
  • Missing or incomplete training records. Particularly individual training records for Infection Control, Information Governance, Complaints and Health & Safety.
  • Make sure the team have a good understanding of safeguarding for children and vulnerable adults, with local referral points identified and easily accessible.
  • Check that you have a valid Legionella Risk assessment and that all recommended checks are being actioned.
  • Inadequate Medical Emergency kit/supplies. Make sure you comply with the Resuscitation Council/GDC guidelines.
  • 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.
  • 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 and learning points.
  • No evidence of tracking, monitoring and reacting to patient safety reports, including CAS and MHRA.
  • The Duty of Candour continues to be checked regularly. Make sure this is understood by all the team and that the procedures/working environment are in place to encourage openness and honesty.
  • Unclear or incomplete patient records have started to feature including the need to show evidence of health advice/best practice and compliance with NICE/FGDP/DH guidelines.
  • Evidence compliance with a preventative approach to dental care in line with DH publication “Delivering Better Oral Health”.
  • Patient records should clearly show treatment options available to patients and evidence of patients making an informed decision.
  • Make sure inexperienced/trainee staff have adequate supervision, mentoring and support.
  • Smaller practices in particular, need to ensure that they have robust referral procedures in place to ensure all patient needs are met and medical concerns escalated.
  • One practice was picked up for not using a rubber dam during root canal treatment
  • Regularly check use-by dates on stock in surgeries, emergency medical supplies and reception consumables to ensure none go out of date.
  • Check that all your dentists are up to date with Radiography training and that you have a Radiation Protection Adviser (RPA) appointed at all times.

As 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 or check our on-line calendar to book a complimentary chat.


CQC Hotspots – November 2016

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