CQC “should haves”

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 compliance@bda.org

•   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.)