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CQC REPORTS

Shoulds

The CQC - when writing a report following an inspection may list actions it wants the providers to take; if there is a breach of the Regulations (ie of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014)), the issue will be highlighted as a “must” on Page 2 and the dentist has to provide an action plan within a specified timescale. However, if the issue needs addressing, but is not urgent, it will appear as a “should”.

The list below was gleaned from 125 CQC reports published on its website between 4th January and 11th February 2016; it is not exhaustive (and may contain duplicates!) and shows a snapshot of the issues found in a proportion of the 1,000 or so practices the CQC is aiming to inspect in 2015/16.

BDA members can refer to the CQC part of our website www.bda.org/cqc - and “Extra” or “Expert” members can contact the BDA’s compliance team to discuss any CQC-related issues/concerns they might have on (0207) 563 4567 or on This email address is being protected from spambots. You need JavaScript enabled to view it.

  •   Patient recalls having regard to NICE guidelines

  •   Review protocols in line with ‘Delivering better oral health”

  •   Effective process established for the on-going assessment and supervision of all staff

  •   Maintain accurate, complete and detailed records relating to employment of staff

  •   Establish complaints system and make it easily available to patients ie waiting room

  •   Review storage of dental care records

  •   Manage medical emergencies inc Resus Council and GDC standards

  •   Tailor all policies and procedures to the practice

  •   Records relevant to the management of the practice available

  •   Review clean to dirty air flow

  •   Review the practice’s sharps procedures (Sharp Instruments in Healthcare

    Regulations 2013)

  •   Check staff immunity for Hepatitis B

  •   Endodontic files clearly labelled with patient info after decontamination

  •   Check and record (CPR) training

  •   Local x-ray rules contain names of authorised staff

  •   Risk assessment on transporting clinical waste

  •   Securing the clinical waste bins to the wall

  •   Review the number of scaler tips that are available for hygienist

  •   Gillick competence awareness training

  •   Review the hygienist referral process

  •   Hands free waste bin

  •   Review storage of cleaning equipment re cross infection

  •   Record keeping audit

  •   Update the information on NHS Choices

  •   Review staff awareness of rinsing instruments

  •   Protocols for dental records in line with FGDP

  •   Reporting mechanism for needle stick injuries

  •   Review interpreter services availability

  •   Ensure the practice's recruitment policy and procedures are suitable (Schedule 3)

  •   Review system for recording, investigating etc significant events

  •   Undertake a Disability Discrimination Act audit

  •   Audits to be undertaken at regular intervals & results shared with staff

  •   Implement daily and monthly water testing

  •   Periodically review policies and procedures

  •   Checks equipment and keep records

  •   Review storage of paper records (DoH code of Practice for Records Management

    (NHS Code of Practice 2006)

  •   Review fire risk assessment & implement

  •   Document action plans for the clinical record audits

  •   Review protocols & procedures using Guidance Notes for Dental Practitioners on

    the Safe Use of X-ray

  •   Radiography audits are undertaken at least annually

  •   Establish a frequent staff meeting cycle

  •   Update radiography Local Rules inc RPS details

  •   Ensure panoramic X-ray machine tested & certified.

  •   Review arrangements for receiving & responding to MHRA alerts

  •   Review policy COSHH storage

  •   Conduct automatic control & steam penetration test (HTM 01-05)

  •   Conduct IPS audit every six months (HTM 01-05)

  •   Conduct weekly check on the AED & oxygen cylinder

  •   Check emergency drug kit

  •   Record in the X-ray machine service record when dose adjustments made

  •   Analyse data from patient satisfaction survey

  •   Repair the floor in surgery

  •   Record COSHH review in folder when done

  •   Repair chair upholstory

  •   Record Legionella review in folder when done

  •   Ensure audits are undertaken at regular intervals & results shared with staff inc

    radiography, infection control & dental care records

  •   Establish a frequent staff meeting cycle

  •   Undertake month water temp tests & recording

  •   Record details when verbal reference is given

  •   New owners should overhaul existing clinical governance systems & processes

  •   Review waste handling protocols in line with (HTM 07-01)

  •   Undertake Legionella risk assessment inc running hot water and temp recording

  •   Ensure training, learning and development needs of staff inc appraisals

  •   Establish systems for manual instrument cleaning are in place

  •   Ensure staff follow agreed written procedure inc audits

  •   Review system for recording, investigating etc significant events

  •   Complete checks from legionella risk assessment

  •   Maintain accurate, complete & contemporaneous for patients receiving a scale and

    polish

  •   Review Gillick competence awareness training

  •   Review system for recording, investigating etc significant events

  •   Ensure practice is compliant (IRR) 99 and (IRMER) 2000

  •   Review protocols for dental records in line with FGDP

  •   Review availability medical emergency equipment (Resus Council & GDC)

  •   Implement a scheduled maintenance plan inc treatment rooms/surgeries

  •   Update infection control audit action plans

  •   Establish a frequent staff meeting cycle

  •   Review protocols on reasons for X-ray & quality (IR(ME)R) 2000 & FGDP

    selection criteria

  •   Review awareness of ‘Delivering Better Oral Health’ toolkit

  •   Review testing procedures for autoclaves & recording process

  •   Establish a “best practice (HTM 01-05) plan

  •   Document patient treatment options

  •   Review protocols for rubber dam use

  •   Replace fabric chairs in surgeries with wipe clean ones

  •   Operate accessible complaints system which identifies, receives, records, handles &

    responds to complaints

  •   Ensure all roles & responsibilities are clearly defined

  •   Undertake actions from fire risk assessment

  •   Undertake regular staff meetings

  •   Periodically review all policies/procedures

  •   Carry out equipment checks

  •   Clearly defining job roles for staff

  •   Implement a lone workers policy

  •   Review system for recording, investigating etc significant events

  •   Obtain child & adult self-inflating bags for emergency resuscitation kit.

  •   Establish system to assess, monitor and mitigate risks for surgery equipment

  •   Conduct frequent autoclave tests (HTM 01-05)

  •   Place signage X-ray room doors

  •   Update staff training matrix

  •   Ensure ultrasonic cleaner tests are completed quarterly

  •   Ensure all staff trained in safeguarding of children & vulnerable adults

  •   Record patient’s ASA (American Society of Anaesthesiologists) status in assessment

    process

  •   Review staff training & availability medical emergency equipment (Resus Council

    & GDC)

  •   Review staff awareness of MCA

  •   Ensure that governance arrangements monitor and assess the quality of the service

  •   Place review dates on policies/procedures

  •   Re-evaluate process for dating pouched instruments & introduce protocol

  •   Review staff’s understanding about obtaining consent from young patients

  •   Update website to clarify it is not fully disabled accessible

  •   Ensure there is proper and safe management of medicines inc stock management

  •   Ensure x-ray audits undertaken regular intervals to improve quality

  •   Record peer review discussions for reflective learning

  •   Review infection control procedures & protocols in line with HTM 01-05

  •   Review procedures to ensure staff CPD up-to-date

  •   Review conscious sedation protocols & audits ('Standards for Conscious Sedation in

    the Provision of Dental Care 2015.) 

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