CQC Hotspots – February 2017


Reviewing a further sample of 54 CQC dental inspection reports published over recent weeks, highlighted a number of compliance breaches which can easily be avoided, but which are still catching out some practices.

Of the 54 practices sampled, 6 practices were issued with breach notifications. Clearly the vast majority of practices are still getting things right, which is great news. All notices reviewed this month were issued for breaches within the Safe and Well Led standards.

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

  • Check to make sure that your recruitment policies and procedures are in place, up to date and followed closely. Particularly with regards to DBS checks, references and evidence of right to work in the UK
  • Ensure you are receiving, checking and taking action on relevant MHRA/CAS patient safety alerts
  • Ensure that patients don’t have access to empty surgeries, which should ideally be locked when not in use, or access restricted
  • Make sure prescription pads are kept securely and not left unattended
  • Always make sure that screens of unattended PCs are locked to avoid unauthorised access and switched off when not required
  • Check your training records are complete and up to date, particularly individual training records for Infection Control, Information Governance, Safeguarding and Health & Safety
  • Dental materials must be kept securely and not accessible to patients
  • Don’t forget to record and keep vaccination records, including Hep B records, up to date for all clinical staff
  • X-Ray equipment should always be switched off at the master switch when not in use
  • General cleaning equipment should be stored securely, colour coded and segregated from clinical cleaning
  • Audits are still seen without essential evidence of learning and action points. Don’t treat audits as a box-ticking exercise, use them to identify and resolve short-comings
  • Make sure you implement recommendations from any risk assessments e.g. regular water temperature checks as part of your Legionella report
  • Remember to clearly define and respect “clean” and “dirty” zones within surgeries and decontamination units
  • All Lab work returned to practice should be disinfected before placement and evidenced on Lab records
  • Inspectors continue to come across missing or partially-completed, mandatory risk assessments including Sharps, Fire, Clinical Waste, COSHH and Manual Handling
  • Remember to date and review all of your practice policies and procedures at least annually. If nothing has changed simply re-date to show that you have been there.
  • Make sure that staff and patients have the opportunity to provide feedback and express concerns. Just as importantly, do something about the feedback and show you have listened
  • Check that dental records are being updated contemporaneously – ie during or immediately after the appointment
  • Some practices still don’t have a Radiation Protection Adviser appointed – this is mandatory
  • Make sure quality and safety audits are carried out on x-ray equipment in line with RPA/manufacturer recommendations
  • Back to basics – don’t forget daily testing and recording of your autoclave equipment
  • The practice is responsible for overseeing CPD training – make sure you keep records of where everyone is within their CPD training cycle
  • Keep on top of your fire log book and mandatory checks of fire equipment including  alarms and emergency lighting
  • Don’t forget to book regular team meetings into the diary – ideally monthly – and keep records of agendas, minutes and action points from each

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 – February 2017

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