The Care Quality Commission (CQC) ‘is an executive, non-departmental public body of the Department of Health’ which ‘was established in 2009 to regulate and inspect health and social care services in England’ (Wikipedia, 2015).

The main role of the CQC is to ensure that hospitals, care homes, dental and GP practices and other health care providers are adhering to standards by which the safe, effective and high quality provision of services is met and/or improved. It was formed from three precursory organizations: the Healthcare Commission, the Commission for Social Care Inspection (CSCI) and the Mental Health Act Commission (MHAC). One of the CQC’s other roles is to protect the welfare of those whose rights are controlled under the Mental Health Act 1983.

Upholding fundamental standards of quality and care is central to the CQC achieving its goals. To this end, the CQC monitors, inspects and regulates dental services registered with it in a bid to encourage improvements and maintenance of standards expected by both the public and Government bodies. Part of an inspection includes listening to and acting on feedback from dental teams based upon their experiences as well as involving patients and gaining their views on services they have used. The CQC works in collaboration with the General Dental Council (GDC) and NHS England, forming a Tripartite Program Board, to take appropriate action if dental service providers are not reaching the standards set. Providers who fall below the standards will be challenged, with the poorest performers receiving the greatest attention and being required to take corrective action. Reporting on dental services is based on ‘fair and authoritative judgements’ and ‘supported by the best information and evidence’.  Publishing of written reports is aimed at empowering the public to make informed choices regarding the dental care services they access.

What were the standards in 2010?

By April 2010, dental care providers were expected to have registered with the CQC and to have started to use its guidance for compliance, Essential standards of quality and safety, to ensure that they complied with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2009 and the Care Quality Commission (Registration) Regulations 2009. Within the guidance, the CQC laid out 28 outcomes, each reflecting a particular regulation. Of these 28 regulations and outcomes, there were 16 that pertained unequivocally to the quality and safety of care and applied generically to all types of provider. The remaining 12 regulations applied in varying ways to different types of provider.

The 28 outcomes could be grouped into six main areas as laid out in Guidance about compliance: Summary of regulations, outcomes and judgement frameworks (March 2010): 

1. Involvement and information

Outcome 1: Respecting and involving people who use services

Outcome 2: Consent to care and treatment

Outcome 3: Fees

2. Personalised care, treatment and support

Outcome 4: Care and welfare of people who use services

Outcome 5: Meeting nutritional needs

Outcome 6: Cooperating with other providers

3. Safeguarding and safety

Outcome 7: Safeguarding people who use services from abuse

Outcome 8: Cleanliness and infection control

Outcome 9: Management of medicines

Outcome 10: Safety and suitability of premises

Outcome 11: Safety, availability and suitability of equipment

4. Suitability of staffing

Outcome 12: Requirements relating to workers

Outcome 13: Staffing

Outcome 14: Supporting workers

5. Quality and management

Outcome 15: Statement of purpose

Outcome 16: Assessing and monitoring the quality of service provision

Outcome 17: Complaints

Outcome 18: Notification of death of a person who uses services

Outcome 19: Notification of death or unauthorised absence of a person who is detained or liable to be detained under the Mental Health Act 1983

Outcome 20: Notification of other incidents

Outcome 21: Records

6. Suitability of management 

Outcome 22: Requirements where the service provider is an individual or partnership

Outcome 23: Requirement where the service provider is a body other than a partnership

Outcome 24: Requirements relating to registered managers

Outcome 25: Registered person: training

Outcome 26: Financial position

Outcome 27: Notifications – notice of absence

Outcome 28: Notifications – notice of change

These outcomes shaped amendments to the law recommended by Sir Robert Francis following his enquiry into poor care and high mortality rates at Mid Staffordshire NHS Foundation Trust. Adherence to these essential standards was intended to reassure patients that care providers would act with high ethics, with morality and within the law. Patients could expect to be treated with dignity and respect and receive dental care tailored to their requirements in a safe and compassionate environment.

Why did CQC standards change in 2015?

The CQC has acknowledged failings within its systems that led to conflict between providers and the CQC. Lack of clarity regarding which requirements were essential as opposed to desirable caused confusion and often hindered the implementation of good standards of dental care. Working out exactly what was required by the CQC resulted in precious time being inadvertently directed away from patient care and focused on computing which CQC requirements were a priority in practice.

In addition to this, Professor Steve Field, Chief Inspector of Primary Medical Services, stated: “We recognise the existing work of other regulatory and oversight bodies, and that the dental sector presents lower risk to patients’ safety. We have therefore started to design our new inspection and monitoring approach on a less frequent model of inspection. This statement sets out our early thinking on how we will do this and how we will work with our partners”. (A Fresh Start for the Regulation and Inspection of Primary Care Dental Services (August 2014) p.4).

This statement reflected a rethinking of the CQC’s strategy during their robust consultation period on proposed changes to be made. Historically, inspections had shown dental services to present a much lesser risk to patients’ safety than other care sectors. Therefore, a decision was taken to inspect 10% of dental practices on a ‘risk and random inspection’ basis as well as those organizations where there is cause for concern. The new strategy, Raising Standards, Putting People First: Our Strategy for 2013 to 2016, marked a new era for inspections and regulation and set out a clear purpose for CQC.

How has the inspection process changed?

The diagram below shows the operational model by which the new strategy works. This model is generic to all care services. However, dental care services will not be rated for the time being.

A New Start (2013) p.7.

 The model displays four key functions:

1. Registration – The way in which providers apply for CQC registration has been reinforced, particularly with regard to how applications are assessed. In order to be registered, providers must demonstrate that they are able to meet the requirements displayed in the regulations. This incorporates two new regulations - Regulation 20: Duty of candour, and Regulation 5: Fit and proper persons: directors. The intention of Regulation 20 is to ensure transparency and openness with service users. Providers need to meet certain obligations if something goes wrong with treatment and care; namely robust and truthful communication about the incident, appropriate support and an apology. Regulation 5 is intended to make sure that anyone with director-level responsibility for meeting fundamental standards is fit and proper to undertake this essential function. Once registered, a provider is legally bound to meet all the regulations.

2. Inspections - Inspections will be carried out by ‘experts’, who will collate data, evidence and information to ‘intelligently’ assess and monitor services. Feedback from staff and patients will allow informed judgements to be made and action to be taken to make improvements. Those who are delivering poor care will be held accountable for it.

The essence of the new approach is patient-centred, with providers required to deliver safe, effective, compassionate and high-quality care. The following questions about providers will be asked during inspections:

• Are they safe?

• Are they effective?

• Are they caring?

• Are they responsive to people’s needs?

• Are they well-led?

Inspections are now consistent and focused by using ‘Key lines of enquiry’ (KLOEs). KLOEs are sector-specific and designed to help inspectors judge the quality of care against the five central questions above. Inspections assess whether the prerequisites presented in the regulations are also met. There are now 11 new regulations that set out the fundamental standards of quality and safety in dentistry and supersede the previous 16 regulations. These new regulations are designed to be clearer assertions of the standards below which care should never falter.

A summary of the changes in regulation is shown in the diagram below:

3. Enforcement – Action will be taken if an inspection identifies concerns and will be proportionate to the severity and impact that the issues pose to the patients that use the service. If fundamental standards are breached, the CQC has power of enforcement, issued by the Health and Social Care Act, 2008, to ‘improve health and adult social care services and protect the health, safety and welfare of people who use them’ Care Quality Commission enforcement policy (February 2015).

4. Independent voice – The CQC will use reports, publications, articles and events to communicate their findings on behalf of service users.

What do dental nurses need to know?

Dental nurses need to be knowledgeable about and mindful of what the inspection teams will be looking for. The majority of inspections are announced, with a notice period of around two weeks. The exception is where the inspection is a ‘focused’ inspection in response to a concern or the identification of sub-standard practices during a previous visit. In this case, inspections can be unannounced. In busy dental practices, preparation time for inspections can be minimal so it is vital that fundamental standards are maintained at all times.

Recent CQC visits have focused on many key areas, including the following:

• Equality, diversity and human rights – The UK has become multi-cultural at a rapid pace and the CQC has specific concerns around communication and cultural differences, particularly with regard to informed consent. In addition to this, some groups within society, including disabled people and homeless people, have difficulty accessing primary dental care for both physical and resource-driven reasons. Inspectors are assessing how dental practices and individual staff are treating vulnerable adults and safeguarding their care based on the principles of ‘fairness, respect, equality, dignity, autonomy, right to life and rights for staff’. These principles are linked to the Human Rights Act 1998 and the Equality Act 2010.

• The Mental Capacity Act (2005) (MCA) – Within dental practices, inspectors are looking at whether the MCA is being used as a framework against which to treat people aged 16 and over who lack mental capacity to make decisions at the time. The aim is to ensure that people’s human rights are being safeguarded, particularly with regard to a person’s capacity to consent to, or refuse, proposed treatment or dental care. In the unlikely event that restraint is necessary and used to administer dental treatment, the CQC is looking for evidence that it is being used necessarily, appropriately and proportionately, in the best interests of the patient and in compliance with the MCA.

• Concerns, complaints and whistleblowing – CQC inspectors will be looking for evidence of how dental practices manage and respond to concerns and complaints made by those using their services. This will include discussing these issues with individual staff members and looking at complaints and whistleblowing policies and complaint handling files as well as speaking with patients. NHS Area Teams may also be asked about concerns, complaints and whistleblowing information that they retain.

• Disposal of mercury waste – Amalgam waste is classed as hazardous waste and as such should not be disposed of into the main sewerage system. Dental practices are required to install amalgam separators that meet British Standard ‘Dental Equipment – Amalgam Separators’ (BS ISO EN 11143:2000) standards and dispose of amalgam waste in accordance with The Hazardous Waste Regulations 2005. Inspectors will be looking for physical evidence of ‘safe’ disposal of hazardous waste as well as practice policies and procedures, consignments notes and staff training and inductions.

• Radiography and X-rays – Dental practices and staff must comply with Ionising Radiations Regulations 1999 (IRR99) and Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R 2000) in relation to patient protection. These regulations are enforced by CQC. Inspectors will be looking for evidence of a designated Radiation Protection Adviser and Radiation Protection Supervisor, a copy of the Local Rules specific to each unit, a practice risk assessment, training for staff and practice policies pertaining to restriction of exposure, maintenance, servicing of engineering controls, contingency plans and controlled areas.

• Medical emergencies – CQC inspectors are looking for evidence that dental practices are following guidance laid out for medical emergencies and staff training updates published by the Resuscitation Council (UK). This includes physical evidence that the practice and staff are prepared to deal with a medical emergency. For example, the necessary drugs and equipment needed to deal with any given medical emergency situation should be on site and located in a central position accessible to all staff. Inspectors are assessing whether quality assurance processes, such as checking drug and equipment expiry dates weekly, are in place.

Conclusion

The regulation and monitoring of dental services is a vast topic area and it would be advisable for those reading this article to study the documents included in the bibliography and reference list. This article has served to highlight the differences between the old and new CQC regulations and inspection methods.  These are summarised in the diagram below.

Author: N Rowland BSc, Dip Man

Bibliography and references

1. www.cqc.org.uk

2. Quick Guide to the Essential Standards, Care Quality Commission, 2010.

3. Guidance about compliance: Summary of regulations, outcomes and judgement frameworks, Care Quality Commission, March 2010.

4. A Fresh Start for the Regulation and Inspection of Primary Care Dental Services, Care Quality Commission, August 2014.

5. Raising Standards, Putting People First: Our Strategy for 2013 to 2016, Care Quality Commission, May 2013.

6. A New Start, Care Quality Commission, June 2013.

7. Consultation on our guidance on the fundamental standards and on CQC’s enforcement powers: A quick guide, Care Quality Commission, July 2014.

8. Care Quality Commission enforcement policy, Care Quality Commission, February 2015.

9. How CQC Regulates Primary Care Dental Services: Provider Handbook, Care Quality Commission, March 2015.

10. http://www.kldc.org.uk/information/cqc-inspection-questions-asked

11. www.docplayer.net

Dental nurses have the ability to push their careers as far as they want to go. Those who develop good knowledge and understanding of their career are the ones that have the power to go beyond dental nursing duties alone. As dental nurses, we have many opportunities to develop our skills and knowledge. We can take on additional responsibility, gain promotions in the workplace, and study for further qualifications. Keeping an open mind and thinking outside of the box is the key to pushing yourself forward in your career.

What do our patients want from us?

Patients want a calm, reassuring dental nurse who is confident in the role; someone they can rely on to comfort them during their treatment. They want someone who is up-to-date with their studying to ensure they are receiving the best care possible.

What do our employers want from us?

Our employers want nurses who can make their businesses grow, who are reliable, and who are popular with their patients.

To meet the needs of both our patients and our employers, we must go above and beyond our job description; this just contains basic expectations. Team members who do more than the average dental nurse are the ones who motivate others and push the business in the right direction. Here are some examples of how to exceed expectations:

• Keep up-to-date with the latest products: impress your employer by researching the latest dental gadgets such as Cerec machines, intraoral cameras or CBT X-ray machines. This shows that you want the best for your patients and that you have an interest in the business.
• Keep up-to-date with industry news: it is always good to know what other practices are doing and what is new in the dental world. This can help to ensure that your practice is on the right track.
• Study for further qualifications: this develops your skills in the surgery and also opens new doors. Dental nurses with extra qualifications tend to be more desirable to work with, which can lead to promotions in the workplace and can even help towards a placement on a hygiene therapy course at university for those who want to develop their careers further.
• Engage in Continuing Professional Development (CPD): this is a GDC requirement, but also expands our useful knowledge. We can learn about new legislation and which toothpaste is the best for sensitivity on the market. This knowledge can then be passed to other team members in the workplace and also to our patients.

Try to imagine your career five years from now. Consider the following questions:

How much would you like to earn?

What would you like to be doing?

What would you like to achieve in that time period?

Now think of ways you can reach your goals. Remember that knowledge is power - the more you know about the business you work in, the more you can give people what they want and the more likely you are to achieve your goals.

Author: R Gibbons RDN

In a world where social media is an intergenerational phenomenon, it seems that to find someone who does not upload their lives online is a rarity. There is a whole generation referred to as ‘digital natives’ who have come of age in a time when internet use is prevalent in everyday life. For many, life before social media is unimaginable!

We are all aware that sites such as Facebook and Instagram are regularly used by prospective employers to gauge a potential employee, by the police to track criminals, and by journalists to gather useful information and witness accounts. People’s online activities leave a footprint that can be accessed by anyone at any time, with many recruiters stating that they will often look at a person’s online presence at the same time as viewing their CV. But do we ever consider where we stand as DCPs and users of social media?

Recently, some nurses have come under fire from the GDC for posting ‘drunken’ photos of themselves online. Although it may seem a little draconian of the organisation to have done this, its views on the use of social media were made quite clear two years ago in the statement:

As a registrant you have a responsibility to behave professionally and responsibly both online and offline.  Your online image can impact on your professional life and you should not post any information, including photographs and videos, which could bring the profession into disrepute.

(GDC, Guidance on using Social Media, September 2013: www.gdc-uk.org)

Many would argue that this is completely unfair; after all, surely what we get up to in our spare time is entirely up to us? If we choose to spend our weekends indulging in what some may consider ‘inappropriate’ behaviour, does it affect our ability to carry out our duties as dental nurses? Many of us will, at some point, have been subject to an embarrassing photo or comment on our social media pages.

Although we can all agree that sharing extreme views online or posting anything that would be considered highly offensive are obviously things to be avoided, it may not be so obvious to some that ‘drunken’ images or videos should be also considered carefully. What we need to bear in mind is that this can be considered ‘unprofessional’ behaviour within what is a professional occupation. Any information we share can be accessed by a vast audience, including our employers, our patients, and - perhaps most significantly - the GDC.

It seems that some nurses have already been advised by their employers about online activities, with one dental nurse who works in West Sussex telling me: “We have been told at work to be very careful about what we put on Facebook, and strictly NO drunken photos of work parties”.

Another newly qualified nurse stated that the practice manager advised some of the team that “…anything that made them seem unprofessional ...” should be removed. This had been after a patient had made an offhand comment about seeing one of the other nurses “enjoying herself a bit TOO much” in an online photo.

One thing that we can do to limit the likelihood of this occurring is to make sure we use the privacy settings on our social media profiles so that only those on our contact lists can view personal photos or comments. Not only does this avoid anyone doubting our professional conduct, it also stops any patients being able to piece together information about our lives that we might prefer to keep private, such as where we live, who our family members are, and our mobile phone numbers (something that Facebook have recently started encouraging users to add to their profile page).

Another key issue that arose when I spoke to a group of nurses is the issue of being ‘friends’ with patients online. A few of them had received ‘friend requests’ which had caused them concern; they felt that they had been added by the patients as they saw them regularly in surgery and had therefore spent time talking to them and getting to know them on a personal level. Although the intention from the patients will have almost definitely been entirely innocent, one nurse said she found it “a bit creepy” and blocked the patient from contacting her on Facebook. Others had deliberated over becoming Facebook friends with patients that they had “known for years” before working at their practices, something that will be unavoidable if you work in a surgery that is local to where you live.

All the nurses agreed that they had considered the professional boundaries we must adhere to, and suggested that being mindful of their social media use in relation to their career as a DCP is something that merely requires a little bit of common sense!

A further point to consider is the sharing of information about patients online. It can be assumed that we would never name patients directly or indirectly on social networking sites (as tempting as it may be to rant after a particularly difficult day in surgery!), but we must also ensure that we maintain this on ‘professional social media’, as outlined in Standard 4.2.3 for the Dental Team, which states:

You must not post any information or comments about patients on social networking or blogging sites. If you use professional social media to discuss anonymised cases for the purpose of discussing best practice you must be careful that the patient or patients cannot be identified.

(GDC, Guidance on using Social Media, September 2013: www.gdc-uk.org)

As long as we bear in mind our professional status, social media use and dental nursing must fundamentally be viewed as a positive partnership. We can use it for our own continuing professional development, seek advice from other DCPs, and keep up to date on the latest dental news. It is also now widely used by most practices as a successful means of marketing, and dental nurses may find they are actively encouraged to help with updating blogs, Facebook and Twitter feeds, and website content.

Being able to use the title of ‘Dental Care Professional’ is something that has elevated our position in the medical sector. To maintain this standing in the profession,  it should be kept in mind at all times, including every time we do something as seemingly insignificant as hit ‘like or ‘share’.

Author: Amy Shipman RDN, BA (Hons)

Introduction

Are changes in infection control procedures in dentistry governed by fact or fiction? In this article I will be looking at key changes in infection control over the last decade and what led to them.

Were they due to actual events of cross-infection which necessitated new procedures and policies, or was it research into diseases that could possibly be transmitted in the dental surgery that led to them? Also, who influences these changes and how?

For many people, visiting the dental surgery creates feelings of fear and anxiety. These fears can stem from people’s own personal experiences, or from hearsay passed along from person to person. It seems that it is these fears and anxieties that can be easily increased with even the slightest mention in the media of any wrongdoing or misconduct in the dental industry. The public are often quick to believe negative stories, which can appear to validate and justify their fears and anxieties.

A famous case that caused much fear and panic occurred in 1990.  It was believed that a young US woman, Kimberly Bergalis, had contracted HIV from her dentist, Dr Acer, after he removed two of her molar teeth. This prompted the Florida Department of Health and Rehabilitative Services to test all of Dr Acer’s other patients. They found six more patients who could link their HIV infection to their dentist. However, the supposed cross-infection was never proven. As the LA Times reported in April 2001, '… to this day, no one can say just how Acer infected his patients with the deadly virus. It is a mystery that most AIDS experts acknowledge may never be solved' (Tanner, L., 2001).

This story created a massive media buzz and worldwide panic that resulted in HIV sufferers being targeted out of fear and misunderstanding. To calm the situation, the American Dental Association recommended that all dentists should wear gloves (Mew, J., 2015). The UK GDC followed suit shortly after.

Even though this case of possible cross-infection was never proven, it highlights the power the media has to influence the public’s perceptions of dentistry. I believe that it is because of these perceptions that the governing bodies need to react. They do this by producing new manuals or implementing new procedures to reassure the public that they are being protected from certain threats - even if these threats are unproven. For example, the big change the above case brought about was the routine use of gloves by dentists in practice.

Research has played a massive part in moving dentistry forward, but it has also created many changes in cross-infection control. Research has found that variant Creutzfeldt-Jakob Disease can be transmitted via prion protein that can be found in the mouth (Ingrosso, L. et al., 1999). Much research has taken place which highlights the possible threat of such transmission, which in turn has led to studies that investigate the safest and most effective ways of eliminating this possibility through certain decontamination processes.

However, these studies have proven unsuccessful, according to an article written by Christine Whitworth, which states that 'Decontamination techniques routinely used in general practice are incapable of inactivating the infected protein responsible for the transmission of the disease' (Whitworth, C., 2002). Furthermore, during a talk at the 6th Annual SWAG conference, Professor Collinge stated that: 'not only are prions not destroyed by sterilisation, but the protein specifically binds to metal, making it very difficult to remove even by good washing' (Collinge, 2003).

A further study was published online in 2008. This explored the effectiveness of a washer disinfector at removing debris from endodontic files. The study originally aimed to 'compare the cleanliness of endodontic files that have be cleaned in a washer disinfector according to the file holder mechanism within the machine' (Assat, M. et al., 2008). However, it went on to prove that the files cannot be totally free from debris, and reinforced the view that such endodontic files should be single use only. The change from reuseable files to single use files was one of the changes that occurred in cross-infection control due to research in the last decade.

The study into the effectiveness of a washer disinfector removing debris from an endodontic file has left me questioning our overall ability to clean instruments to a satisfactory level. The HTM 01 05 highlights that using washer disinfectors in practices is seen as best practice - but there is very little research proving that this the most effective method of decontamination. Is it just an added step in the decontamination process that is there to reassure the public that everything is being done to decrease the risk of cross-infection (even if this step is more timely and expensive than is necessary?)

Conclusion

Decontamination in dentistry will continue to change and progress. Changes can be initiated by a widely covered media story that prompts changes in order to counter negative public perceptions. Changes can also be a result of research that highlights a threat of a possible transmissible disease - this is combatted by adding precautionary steps to the decontamination process.

Overall, whether these changes come from the media or from vital research, it is clear that the dental industry will always aim to create decontamination processes that are proven to help protect patients from-cross infection. Even if processes have been created but have not yet been proven to be the most effective, it is reassuring to know that they seem to adopt an attitude of 'it's better to be safe than sorry'. It is because of this attitude that I, as a dental professional, feel safe in the knowledge that cross-infection control in dentistry will always evolve to provide the utmost protection for me and the general public in the future.

Author: Amba Williams, RDN, Level 3 Cert Dental Decon.

References

Assat, M., Mellor, A. & Qualtrough, A.J. (23rd May 2008) Cleaning endodontic files in a washer disinfector.  British Dental Journal Vol 204 (E17), DOI: 10.1038/sj.bdj.2008.411

Houghton, K. (2004) Journal of one day surgery proceedings of the 6th annual SWAG conference. Vol 14(2) 13-16 (online) available from http://dayssurgeryuk.net/en/resources/journals.of.one.day.surgery/previous-journals/?p=10

Ingrosso, L., Pisani, F. & Pocchiari, M. (1999) Transmission of the 263K scrapie strain by the dental route. J Gen Virol 1999 (80) 3043–3047

Mew, J., (24th April 2015) Glove wearing: an assessment of the evidence. British Dental Journal Vol (218) 451-452. DOI: 10.1038/sj.bdj.2025.292

Tanner, L. (2001) (online) available at http://articles.latimes.com/2001/apr/01/news/mn-45203

Whitworth, C. (1st July 2002) Variant Creutzfeldt-Jakobz Disease- A problem for General Dental Practitioners Vol 9(3) 95-99 (5) DOI: 10.1308/135576102322492945