CQC Hotspots – March 2017

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Reviewing a further sample of 56 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 56 practices sampled, 5 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 Well Led standard.

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.

  • Every month, two or three practices are being picked up on inadequate recruitment and staff induction procedures. Follow simple checklists and procedures to demonstrate that you are doing things correctly and keep records in staff files.
  • Ensure you are receiving, checking and taking action on relevant MHRA/CAS patient safety alerts. Dental practices don’t receive many but there must be a robust system in place to show that you identify and respond to any that are published.
  • Ensure that all sterilisation and clinical equipment is externally validated by professionals/suppliers in addition to the recommended routine/daily/weekly checks you are required to undertake.
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  • 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.
  • X-ray audits for quality and justification should be undertaken for each dentist, not on an individual surgery/equipment basis, as this could leave some dentists unchecked. Records should show all dentists are regularly audited.
  • Prescription and controlled medicines/drugs must be locked away and closely monitored.
  • Management of sharp injuries are regularly checked. Ensure procedures are in place and communicated to all the team. Incident/Accident Reporting records must be updated for each event.
  • The practice Health & Safety risk assessment must be kept up to date and where new or changed risks are identified, actions put in place to resolve quickly. Don’t delay as once identified, you have a responsibility to correct.
  • Check your electrical system inspections and certificates are all in place and up to date including Portable Appliance Testing. Frequency of re-test will be confirmed during each visit/inspection. More details from the Health & Safety Executive here.
  • 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.
  • Don’t forget that associate dentists, therapists and hygienists should also have annual appraisals to review performance and identify training requirements.
  • Collecting and responding to patient feedback and comments is essential. Don’t just rely on the NHS Family & Friends test, which is just one specific measure.
  • Make sure that the Registered Manager/CQC lead has adequate time to complete all their duties and responsibilities. Practices have been picked up where the Principal dentist/owner has day to day responsibility but is in surgery for the majority of the week.
  • Take care with “Off the Shelf” or “In a Box” Policy and Procedure packs. They are an essential and valuable source of material for many practices, but each policy/procedure must be reviewed and personalised to the practice and the way you work.
  • Make sure that all the named individuals/leads in your policies/procedures still actually work at the practice. Update and replacement is essential.
  • 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.
  • Ensure your fire procedures make provision for evacuation of patients with disabilities.
  • Don’t forget to book regular team meetings into the diary – ideally monthly – and keep records of agendas, minutes and action points from each. It is not enough for staff to say that everything is discussed and resolved informally during the working day.

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 – March 2017

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