Quality Check Summary

Our approach

Healthcare Inspectorate Wales (HIW) undertook a remote quality check of Village Dental Practice as part of its programme of assurance work. The practice offers a range of NHS and private dental treatments.

HIW’s quality checks form part of a new tailored approach to assurance and are one of a number of ways in which it examines how healthcare services are meeting the Health and Care Standards 2015 (and other relevant regulations). Feedback is made available to service representatives at the end of the quality check, in a way which supports learning, development and improvement at both operational and strategic levels.

Quality checks are a snapshot of the standards of care within healthcare services. They are conducted entirely offsite and focus on three key areas; infection prevention and control, governance (specifically around staffing) and the environment of care. The work explores arrangements put in place to protect staff and patients from COVID 19, enabling us provide fast and supportive improvement advice on the safe operation of services during the pandemic. More information on our approach to assurance and inspections can be found here.

We spoke to the Registered Manager and Principal Dentist on 20 May 2021 who provided us with information and evidence about their service. We used the following key lines of enquiry:

• ·  What changes have you implemented in light of COVID-19 to ensure infection prevention and control standards are maintained?

• ·  How are you ensuring that all patients (including vulnerable/at risk groups) are able to access services appropriately and safely?

• ·  How has the practice and the services it provides adapted during this period of COVID- 19?

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Environment

During the quality check, we considered how the service has responded to the challenges presented by COVID-19 and how the service has designed and managed the environment of care to keep it as safe as possible for patients, staff and visitors.

The key documents we reviewed included:

• ·  the practice risk assessment for COVID-19 resuming dental services

• ·  most recent fire risk assessments action plan

• ·  most recent health and safety risk assessment action plan

  We also questioned the service representatives on the changes they have made to make sure patients continue to receive care and treatment according to their needs.

  The following positive evidence was received:

  We were told about the changes that had been made to the practice environment as a result of the pandemic. Personal Protective Equipment (PPE) for staff and patients is available as well as hand sanitizing stations throughout the practice. Cleaning schedules had been amended to enable more frequent cleaning. We were told that the practice were updating their own Standard Operating Procedure (SOP) in line with updates and advice from external bodies. This included the guidance issued within the Standard Operating Procedure for the dental management of non-COVID-19 patients in Wales. We were told that where possible, staff teams would remain consistent to minimise unnecessary contact between other staff members.

  We were told about the changes made to the environment to minimise the risk of COVID-19 transmission within the communal areas and treatment rooms. These included social distancing measures and only patients with pre-arranged appointments could visit the practice. Furniture and seating had been removed from the waiting areas. Treatment rooms had been cleared of all unnecessary items.

  We were told that patients are asked to attend their appointments on time and not arrive earlier due to the lack of patient waiting areas. The doors to the practice remain closed until the surgery in which the patient being treated is ready to receive them. Patients were required to use the intercom system installed outside to notify the practice of their arrival. A one way system around the practice has been put in place to minimise contact between staff and patients. Upon entering, staff undertake temperature checks on all patients which are recorded, a face mask is provided (if required) and hand sanitizer given. The patient is then escorted to the treatment room.

  We were told that COVID-19 risk assessments had been completed for all staff. Depending on the outcome of the assessment, the practice would determine if the staff member needed

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to shield1 or undertake a different role within the practice.

We were told that all surgeries were equipped to perform Aerosol Generating Procedures

2
(AGP) . Mechanical ventilation had been installed to facilitate the removal of contaminated

air. Surgeries were subject to fallow time3 following AGP procedures in line with their ventilation system.

In order to allow adequate time to disinfect the surgery between patients, a reduced amount of appointments were available. Staff stated that this had impacted on availability of appointments, but this was being managed effectively to ensure patients could still access the care that they needed.

We saw evidence of a COVID-19 specific risk assessment which was regularly reviewed, and an environmental risk assessment that had been updated in June 2020. Existing controls or action required were documented within the assessments, along with the actions taken to address these risks.

No areas for improvements were identified.

Infection prevention and control

During the quality check, we considered how the service has responded to the challenges presented by COVID-19, and how well it manages and controls the risk of infection to help keep patients, visitors and staff safe.

The key documents we reviewed included:

• ·  COVID-19 policy

• ·  Infection control policy

• ·  the most recent Welsh Health Technical Manual (WHTM) 01-054 decontamination audit

  and the action plan to address any areas for improvement

• ·  surgery cleaning schedules

• ·  records of daily checks of autoclaves

• ·  Most recent infection control risk assessments / audits

• ·  Cleaning schedules.

  1 This word is used to describe how people at high-risk should protect themselves by not leaving their homes and minimising all face-to-face contact.
  2 An aerosol generating procedure (AGP) is a medical procedure that can result in the release of airborne particles (aerosols) from the respiratory tract when treating someone who is suspected or known to be suffering from an infectious agent transmitted wholly or partly by the airborne or droplet route.

  3 Fallow time refers to the time required following an AGP to allow the air to be circulated and infection causing particles to be removed from the surgery
  4 WHTM 01-05 includes information on an audit of compliance with decontamination. The audit has been developed by dentists in Wales and is supported by the Dental Section, HEIW.

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The following positive evidence was received:

We were provided with various documents for the prevention and control of infection, which included Protocols and Risk Assessments for working during the Coronavirus Pandemic. We saw evidence of an Infection Prevention and Control (IPC) audit, together with practice cleaning schedules and records for the decontamination of instruments and dental equipment.

We were told about the systems that are in place to ensure all staff were aware of, and discharged their responsibilities for preventing and controlling infection. This was evidenced in the practice’s SOP document which set out the actions and responsibilities of management and staff in order to prevent the spread of the virus. In addition, we were told that PPE training, including mask training and donning and doffing of PPE had been delivered to all staff. Weekly audits of donning and doffing were being undertaken in the practice.

Due to social distancing, staff meetings had been moved to video calls during the height of the pandemic, although the practice was now using a mixture of virtual and physical meetings when social distancing measures could be met. Meetings were held on a monthly basis to ensure all staff had access to the most up to date procedures for working during the pandemic.

We were told that before each treatment session, dental nurses were responsible for arranging the equipment required for all appointments and boxing them up ready to be easily accessed. This is designed to minimise staff entering or leaving the surgery during the procedure.

Staff explained that patients were contacted prior to their appointment and asked a series of questions to determine whether they were at risk of transmitting the virus. On arrival at the practice, patients have their temperature taken and follow the procedure set out in the SOP for ensuring staff and patient safety when entering the practice. Patients who were displaying symptoms or were awaiting results of a COVID-19 test were instructed to stay home and not attend the practice.

The practice stated they had sufficient stock of PPE and that regular stock checks are undertaken. We were told that a member of staff oversees the central stocks and orders are placed via an online system on a regular basis.

No areas for improvements were identified.

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Governance / Staffing

As part of this standard, HIW questioned the service representatives about how, in the light of the impact of COVID-19, they have adapted their service. We explored whether management arrangements ensure that staff are suitable in their roles and are appropriately trained in order to provide safe and effective care.]

The key documents we reviewed included:

• ·  Statement of Purpose

• ·  Patient Information Leaflet

• ·  Ionising Radiation (Medical Exposure) Regulations (IRMER) audit

• ·  Record card audit

• ·  Informed consent policies / procedures

• ·  Standard Operating Procedure for Covid-19

• ·  Business continuity plan

• ·  Mandatory training completion rates for all staff

  The following positive evidence was received:

  We saw evidence of training records, which showed compliance with mandatory training. Staff also explained the process for ensuring training was up to date. Staff continued to use e- learning5 packages for Continued Professional Development (CPD). In addition, small group face to face training could be arranged for staff when appropriate, to ensure skills and knowledge remain up to date.

  We were told that the practice did not close during the initial stages of the pandemic. Throughout the pandemic the practice has maintained a service to continue to see emergency patients, following screening for COVID-19. For patients exhibiting symptoms of Covid-19 who needed urgent dental care, there was a service in place with the health board which the practice could refer patients to. This ensures patient care can be delivered according to their needs.

  We were told about the arrangements and actions taken to date when staff members needed to self-isolate or tested positive for COVID-19. We were provided with a detailed account of the procedure and given examples of how this has worked to date. We were satisfied that these procedures minimised the risk of spreading COVID-19 to staff and patients.

  The practice has maintained their processes for the reporting of any incidents, with the principal dentist and registered manager having an oversight of any incidents. We were told that staff were aware of their roles and responsibilities in reporting incidents to regulatory agencies including Healthcare Inspectorate Wales (HIW), and this process was explained in

  5 Learning conducted via electronic media, typically on the internet.

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detail. Any updated guidance for healthcare professionals was delivered in regular staff meetings and emails.

The process of checking emergency equipment and medicines was explained. One member of staff has responsibility for performing the checks and checking the findings in line with information held in online software. The software used also allowed the practice to receive electronic updates when items were coming to the end of their shelf life, providing the practice with a second layer of protection.

We were informed that the practice also kept a secondary kit in place to allow for domiciliary care, however during the Covid-19 pandemic this care option had stopped. Instead, the practice had arrangements in place with local care homes to receive patients in the practice, with enhanced protection measures due to the vulnerability of the patients. We were told that this emergency kit was kept in line with practice kit.

We reviewed the patient information leaflet6 and statement of purpose7, which contained all the required information and are available from the practice upon request.

No areas for improvements were identified.

6 Information as required by Schedule 2 of the Private Dentistry (Wales) Regulations and Schedule 1.
7 “Statement of purpose” means the statement compiled in accordance with regulation 5(1) of the Private Dentistry (Wales) Regulations and Schedule 1.

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What next?

Where we have identified areas for improvements during our quality check and require the service to tell us about the actions taken to address these, an improvement plan providing details will be provided at the end of this quality check summary.

Where an improvement plan is required, it should:

• ·  Ensure actions taken in response to the issues identified are specific, measurable, achievable, realistic and timed

• ·  Include enough detail to provide HIW and the public with assurance that the areas for improvements identified will be sufficiently addressed

• ·  Ensure required evidence against stated actions is provided to HIW within three months of the quality check.

  As a result of the findings from this quality check, the service should:

• ·  Ensure that the areas for improvements are not systemic across other areas within the wider organisation

• .  Provide HIW with updates where actions remain outstanding and/or in progress, to confirm when these have been addressed.

  The improvement plan, once agreed, will be published on HIW’s website.

  If no areas for improvement were identified during this quality check, an improvement plan will not be required, and only the quality check summary report will be published on HIW’s website.

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