CQC “must haves”

CQC REPORTS

“Musts”

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 compliance@bda.org

•   Ensure availability and checks of all medicines in line with BNF and Resus Council

•   Record in the patients’ dental care records and reason/quality of X-ray

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

•   Undertake CPR training

•   Ensure all staff receive necessary training and performance appraisals

•   Process in place for recording accidents

•   Protocols for dental records in line with FGDP

•   Establish a complaints process

•   Equipment is safe for use and used safely

•   Processes that make sure that people are protected from abuse

•   Ensure sufficient numbers of suitably qualified staff

•   Establish system to assess, monitor and mitigate risks

•   Seek views of patients and show how they are taken into account

•   Training, learning and development needs of staff

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

  radiography, infection control & dental care records

•   Review conscious sedation protocols & audits (‘Standards for Conscious Sedation in the Provision of Dental Care 2015’)

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

•   Ensure decon equipment is safe & effective

•   Ensure waste is stored securely & disposal is in line with (HTM 07-01)

•   Undertake Legionella risk assessment

•   Ensure practice has written waterline management scheme

•   Review policy COSHH storage

•   Ensure staff know about infection prevention control

•   Establish system to assess, monitor and mitigate risks

•   Review systems to seek & act on patient & staff feedback

•   Review staff awareness of MCA

•   Ensure staff have the qualifications, competence, skills and experience

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

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

•   Ensure premises and equipment used are safe to use and are used safely

•   Ensure practice meets fire safety guidance

•   Assess risk of, and preventing, detecting and controlling the spread of infections

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

  responds to complaints

•   Review systems to seek & act on patient & staff feedback

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

  selection criteria

•   Ensure staff have necessary immunisation (Hepatitis B)

•   Review protocols for dental records in line with FGDP

•   Ensure staff have necessary immunisation (Hepatitis B)

•   Ensure there is proper and safe management of medicines

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