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CQC Transitional Monitoring Approach Guidance – Dental
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The CQC has evolved its approach to regulating as the risks from the coronavirus pandemic change, by using a transitional approach to monitoring services.
The focus is on:
• Safety
• How effectively a service is led
• How easily people can access the service
The new approach includes:
• A strengthened approach to monitoring, based on specific existing key lines of
enquiry (KLOEs) so that risk in a service can be monitored
• Using technology and local relationships to better direct contact with people who
are using services, their families and staff working in the service
• Targeting inspection activity where there are concerns
Once the CQC have reviewed information about your service, you will have a conversation online or via telephone. This is not an inspection and you will not be rated from this. It will help decide if further regulatory action is needed.
Information considered about a service
The CQC will consider:
• Previous inspection reports and ratings
• Monitoring information collected through usual data sources and an inspector’s knowledge of the services
• Views of people who have used the service from online feedback, such as google
reviews, practice website, social media platforms plus enquiries and
information from other agencies
Where more information is required, the CQC will contact you for further information.
Monitoring
A call will be arranged with you and can take an hour or two, but some may be shorter. Microsoft Teams will be used where possible, if not a telephone call will be arranged.
The call will be around the specific KLOEs for your type of service and the inspector will note details around the discussion you have, noting any risk areas identified and examples of good practice and improvements to the service.
The inspector may also request evidence during the call and will allow screen sharing or attachments to be sent on an encrypted or protected email. If evidence cannot be sent on the call it must be sent to the inspector within 24 hours of the call. This will only be done where
necessary.
Audio recordings will not be taken unless your consent is gained. An overall monitoring
summary of findings will be prepared after the call.
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The monitoring summary record is not an inspection report, and no ratings are given, as such the factual accuracy process does not apply. Monitoring summary records will not be published on the CQC website and should not be shared publicly.
Monitoring Outcome
Where an inspection or other regulatory action is not needed, a copy of the monitoring summary record will be sent.
Where risks are identified to the safety of people using the service, further regulatory action may be taken, including help to find additional sources of support for the service, an inspection to be carried out or enforcement processes. A monitoring summary record will not be sent in such cases and the necessary action will be taken.
Monitoring Questions for Providers
During the inspector’s call they will focus on the specific key lines of enquiry below. The types of detail asked within each KLOE is also recorded with some guidance from QCS on potential examples, policies and documents to refer to for evidence of these:
SAFE
S1: How do systems, processes and practices keep people safe and safeguarded from abuse? Potential Evidence
How do you ensure staff
recognise safeguarding issues
for adults, children, and other
vulnerable people, and that they
take appropriate action?
• Safeguarding notifications and records
• Feedback from Local Authority/Safeguarding teams
• Safeguarding Policy and Procedure
• Safeguarding Children and Child Protection Policy
• Mental Capacity Act (MCA) 2005 Policy and
Procedure
• Protecting Vulnerable People from
Radicalization Policy and Procedure
• Appropriate level of training for individual staff
members – as a standard level 2 is expected
How do you ensure that the
management of any
safeguarding concerns does
not discriminate people, and
that their human rights are
protected?
• Equality and Human Rights Policy and
Procedure
• Consent Policy and Procedure
• Update staff training in Safeguarding, FGM,
Radicalisation, Domestic Violence
• Document regular Safeguarding staff meetings
• Check for regular updates on local Safeguarding
board websites
• Display Safeguarding flow chart and safeguarding
lead details for all staff to see
• Patient feedback
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What are your arrangements to
respond to medical
emergencies?
• First Aid and Medical Emergency Policy and
Procedure
• Management of Medical Devices Policy and
Procedure
• Accident and Incident Reporting Policy and
Procedure
• Demonstrate staff training in BLS updated
annually or ALS if offering sedation services
(both clinician and assisting nurse)
• Use of panic button on dental software to alert
other staff members to an emergency
• Evidence regular meetings discussing medical
emergency arrangements and role
play/scenario- based training on how to respond
to a medical emergency
• Check lists and regular spot checks on
equipment and emergency drugs
• Handover forms for Ambulance service –
detailing the event, staff present, materials used,
medication used – batch numbers and expiry
dates
Where you have moved to remote
consultations (telephone and
video consultations)? How do you
identify vulnerable people or
people who might be digitally
excluded because of
communication barriers (for
example, because of a disability or
poverty)?
• Video Consultations Policy and Procedure
• Antimicrobial Prescribing Policy and Procedure
• Refer to the GOV.UK Guidance on shielding and
protecting people who are clinically extremely
vulnerable from COVID-19
• Equality and Diversity Policy and Procedure
• Equality and Human Rights Policy and Procedure
• Update and maintain staff training as and when
guidance changes and update SOP to reflect this
• Follow SOP in regard to appropriate triaging
procedures
• Evidence practices meetings
• Dental Care Communication and Information
Policy and Procedure
• Communication Policy and Procedure
• Patients with Communication Difficulties Policy
and Procedure
• Patient feedback
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S2: How are risks to people assessed, and their safety monitored and managed, so they are supported to stay safe?
Infection Control Potential Evidence
What changes have you made
to infection control
arrangements to protect staff
and patients using the service?
• How have you made the Practice COVID secure?
E.g. screens, revised cleaning schedules, break
areas, social distancing with work areas
• Created a Standard Operating procedure and
shared with all staff
• Adequate training of staff to demonstrate
enhanced cross infection procedures after an
AGP
• Introduction of Fallow time or reduction of Fallow
time using certified Extraction fans with >10-12
ACH
• *Sessional mopping of the floors
• Enhanced PPE – including FFP3 masks, full face
visors, gowns and aprons
• Controlled waiting room – monitoring how many
patients are in the waiting room at any one time
• Infection Control and Decontamination Policy and
Procedure
• Personal Protective Equipment (PPE) Policy and
Procedure
• Assessing and Reducing Risk to Workforce
(COVID-19) Policy and Procedure
• Coronavirus Policy and Procedure
• Pandemic Policy and Procedure
• Staff Immunisations Policy and Procedure
• Premises Cleaning Policy and Procedure
• Hand Hygiene Audit Tool
• Signage (internal and external)
• Patient notices about social distancing, face
coverings and hand washing/sanitising
• Risk Assessments e.g. Risk of Showing
Symptoms of Coronavirus (COVID-19), Risk
Assessment for Staff (Including Vulnerable
Groups During COVID-19), Staff Immunisations
• Encouraging staff to have the vaccine, and
directing them via the correct pathway
• The Practice website and social media have been
updated with appointment, prescription collection
and visiting information
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• Locked door policy
• Updated patient journey
• Paperless interaction such as signing forms on
patients' behalf etc.
How do you ensure that staff have
the appropriate time for
donning/doffing and cleaning
between seeing patients?
• Personal Protective Equipment (PPE) Policy and
Procedure
• The procedures you have in place to allow
additional time e.g. longer
• appointment times, zoning of appointment book
• Staff input and feedback
When was your last audit of
IPC/PPE/the environment and
facilities? What did it tell you and
what actions have you taken?
• Infection Control and Decontamination Policy
and Procedure
• Audit Policy and Procedure
• Clinical Waste Disposal Policy and Procedure
• An IPC audit has been carried out in the last 6
months
• Any IPC actions are documented and with
target and completion dates
• Updated training and CPD
Safety systems and risks to people Potential Evidence
What actions have you taken in
the last six months as a result of
learning from serious incidents to
ensure that people are kept safe?
• Serious Incident Notification Policy and
Procedure
• Hazard Reporting Policy and Procedure
• Significant Event Policy and Procedure
• Accident and Incident Reporting Policy and
Procedure
• Quality Meetings Policy and Procedure
• Management Meetings Policy and Procedure
• COVID-19 Secure Workplace
• Risk Assessments e.g. Pandemic Threats by
Infectious Diseases Risk Assessments
• COVID–19 Practice Management Policy and
Procedure
• Health and Safety Policy and Procedure
• Health and Safety Training Policy and Procedure
• In-house training documenting relevant changes
to procedures
• All documented actions discussed at relevant in-
house meetings
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How are patients who need
urgent care and treatment
identified, prioritised, and protected
from discrimination?
• Video Consultations Policy and Procedure
• Referral Policy and Procedure
• Appropriate triaging procedures
• Training evidence for staff
• Describe and provide evidence of your processes
for treating patients who need urgent care
• Referral to Urgent Dental Care Hubs- following
referral criteria
• Tracking, monitoring and following up on
referrals
How do you recognise and
manage the deteriorating
patient?
• Patients with Communication Difficulties Policy
and Procedure
• Patient Involvement Policy and Procedure
• Management of Oral cancer and implementing
the Two Week Wait urgent referral form
• Referral Policy and Procedure
• Appropriate triaging procedures to recognise
dental trauma or life-threatening dental
swellings
• Evidence of staff training on when to seek
secondary care in a dental emergency
• Describe how you maintain your list of
vulnerable, or clinically Vulnerable patients and
how they are prioritised in the diary – such as
vulnerable clinics first thing in the morning
How do you ensure appropriate
staffing levels and skill mix to
cope with demand? (For example,
weekends, bank holidays, seasonal
pressures, epidemics)
• Staff rota Policy and Procedure
• Recruitment Policy and Procedure
• Training Policy and Procedure
• Agency Staff Policy and Procedure
• Business Continuity Policy and Procedure
• Annual Holiday Policy and Procedure
• Unable to Attend Workplace Policy and
Procedure
• Outbreak Management Policy and Procedure
• Sickness Absence Policy and Procedure
• Absenteeism Policy and Procedure
• Furlough Policy and Procedure
• Training records and CPD logs
• Staff Attendance Record
• Rota Management
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• Details of how the team was managed - i.e.
teams were split into two groups or split shifts
to avoid transmission within the team
• Advise staff to turn off track and trace app while
in work
• If there was a transmission within the workplace,
how did you handle this? What procedures did
you follow?
Do you provide conscious
sedation? If yes, how do you
ensure that risks are assessed,
monitored and managed so that
sedation is delivered in a safe
and effective way, in line with
published standards?
• Refer to the Sedation Policy and Procedure
• Ensure that staff are appropriately trained in
sedation and hold current qualification and
indemnity to perform the regulated activity
• First Aid and Medical Emergency Policy and
Procedure
• Management of Medical Devices Policy and
Procedure
• Risk Management Policy and Procedure
• Both Clinician and assisting nurse must be
trained to ALS
• Follow SAAD guidelines
• Ensure that two oxygen cylinders are on site at
all times
• Ensure that all appropriate safety checks and
logs are carried out and audited appropriately
How do you identify and manage
patients who need a face-to-face
appointment?
• Video Consultations Policy and Procedure
• Appointment Book Management Policy and
Procedure
• Treatment Policy and Procedure
• Pandemic Policy and Procedure
• Patient Involvement Policy and Procedure
• COVID-19 Practice Management policy and
Procedure
• Describe how patients are triaged and assessed
for a face-to-face appointment
• Evidence how you pre–screen patients prior to
appointments for signs and symptoms of
COVID-19
• Discuss Patient Journey and SOP
How are you managing clinical
capacity to provide safe oral
health treatment and support?
• Video Consultations Policy and Procedure
• Appointment Book Management Policy and
Procedure
• Treatment Policy and Procedure
• Pandemic Policy and Procedure
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• Zoning diaries to include appropriate clinics
• Fallow time calculator
• Maintain records of who is triaged, referred and
seen face to face and then how you follow up
these patients
• How do you Manage the staff rota to fill
available surgeries and facilitate fallow time?
• Maintain good training records
What are your systems to support
staff to work remotely where this is
appropriate and required?
• Home Working Policy and Procedure
• Data Protection and Confidentiality Policy and
Procedure
• Confidentiality and Data Protection checklist
• Display Screen Equipment Policy and Procedure
• Employee Welfare Checklist
• Flexible Working Policy and Procedure
• Emergency Communication Policy and
Procedure
• Daily Communication Policy and Procedure
• Stress and Mental Health in the Workplace
Policy and Procedure
• Assessing and Reducing Risk to the Workforce
(COVID-19) Policy and Procedure
• Discuss how you support staff and manage
their workload throughout the day
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S3: Do staff have all the information they need to deliver safe care and treatment to people?
Potential Evidence
How do you manage clinical
records to ensure safe care and
treatment?
• Record Keeping Policy and Procedure
• Archiving, Disposal and Storing of Records
Policy and Procedure
• Obtaining Medical Reports Policy and Procedure
• Clinical Record keeping Audit – every 12 months
• Consent Policy and Procedure
• Treatment Plan Policy and Procedure
• Treatment Plan Audit tool
• Data Security and Data Retention Policy and
Procedure
• Training of staff on accurate record keeping
• How have you included triaging notes? Did you
create a template?
• Staff meeting minutes
How do you manage referrals to
and from other providers?
• Referral Policy and Procedure
• Referral to Urgent Dental Care Hubs - following
referral criteria
• Tracking, monitoring and following up on
referrals
• Computer, Email and Internet Usage Policy and
Procedure
• Data Protection and Confidentiality Policy and
Procedure
• Breach Notification Policy and Procedure
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S4: How does the provider ensure the proper and safe use of medicines, where the service is
responsible?
Potential Evidence
Have you made any changes to your
approach to medicines
management? (For example, in
relation to repeat prescribing,
ongoing monitoring requirements for
high-risk medicines)
• Antimicrobial Prescribing Policy and
Procedure
• First Aid and Medical Emergency Policy and
Procedure
• Prescription Security and Management Policy
and Procedure
• Prescription Security and Management Policy
and Procedure
• Antimicrobial Prescribing Policy and
Procedure
• Describe and evidence AAA prescribing and
safe electronic security of sending scanned
prescriptions - i.e. NHS.net email address
• Auditing Prescriptions
• Logging and monitoring Prescriptions
• How do you follow up on these prescriptions?
Did it result in a UDC referral?
If so, what, and how has this affected
care?
• Discuss antibiotic resistance in over
prescribing
• Discuss increase in loss of teeth due to lack
of face-to-face treatment in first lockdown
• Discuss link to prescribing and UDC referrals
• Discuss how it impacted root canal vs
extraction ratios
• Discuss the changes in your pre-COVID
audits to your most recent audit
How are people’s medicines
reconciled, in line with current national
guidance, when transferring between
locations or changing levels of care?
• NICE Guidelines
Have you made any changes to
antimicrobial prescribing? If so, how
has this affected care?
• Describe and evidence any changes you
have made and how this has affected care
• Patient feedback
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EFFECTIVE
E1: Are people's needs assessed and care and treatment delivered in line with current legislation,
standards, and evidence-based guidance to achieve effective outcomes?
Potential Evidence
How are you identifying, cascading
and keeping up to date with changes
in clinical guidance?
• Primary Care Bulletins
• CDO updates
• QCS Resource Centre and Updates
• CQC Updates
• NHS England website
• FGDP updates
• SDCEP updates
• PHE Website
• LDC emails/newsletters
• BDA website
• NHS Digital Website
• NICE website
• Quality Meetings Policy and Procedure
• Management Meetings Policy and
Procedure
• Regular COVID staff meetings
• Staff are provided with regular training and
instruction as guidance changes
What are your oversight arrangements
for clinical care provided by clinical
and non-clinical staff?
• Supervision Policy and Procedure
To people in care homes • Only applicable to Residential Care
• Feedback from patients
To vulnerable people in their own
homes
• Only applicable to Domiciliary Care
• Feedback from patients
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E3: How does the service make sure that staff have the skills, knowledge and experience to
deliver effective care, support and treatment?
Potential Evidence
How do you ensure that all staff (clinical and
non-clinical), including those being flexibly
re-deployed, have the skills and knowledge to
carry out their roles and responsibilities
effectively?
• Recruitment Policy and Procedure
• References Policy and Procedure
• Development Appraisal Policy and
Procedure
• Training Policy and Procedure
• COVID-19 Testing Policy and
Procedure
• Management Meetings Policy and
Procedure
• Contingency Plans
• Evidence of Practice training days
• Evidence of Fit testing
• Evidence of COVID-19 vaccination
• Lateral flow testing logs
• Practice Reporting arrangements
• Discuss how you have kept staff
updated throughout
• Meetings around transition back to
face-to-face dentistry
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E5: How are people supported to live healthier lives and, where the service is responsible,
how does it improve the health of its population?
Potential Evidence
How do you ensure that people
who are affected by health
inequalities are receiving the care
they need?
• Quality Meetings Policy and Procedure
• Quality Assurance Policy and Procedure
• Equality and Human Rights Policy and
Procedure
• Equality and Diversity Policy and Procedure
• Transgender Policy and Procedure
• Dental Care Communication and Information
Policy and Procedure
• Patients with Communication Difficulties Policy
and Procedure
• Patient Involvement Policy and Procedure
• Referral Policy and Procedure
• Displaying important patient information on
social media platforms/website and in Practice
telephone messages
• Ensuring that patients have access to expert
advice and a robust referral process
• Operating out of hours services in line with
contractual arrangements
• Evidence that all patient contacts are
• followed up
How are you promoting good
health/targeted approaches in
response to coronavirus
(COVID-19) and people at risk?
• Information available on the Practice website
and social media
• Continuing with health screening programmes
such as Oral cancer awareness week, World Oral
Health Day, Mental Health week and smoking
cessation campaigns
• Staying updated via:
• Primary Care Bulletins
• CDO updates
• QCS Resource Centre and Updates
• CQC Updates
• NHS England website
• FGDP updates
• SDCEP updates
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• PHE Website
• LDC emails/newsletters
• BDA website
• NHS Digital Website
• NICE website
• Quality Meetings Policy and Procedure
• Management Meetings Policy and
Procedure
• Regular COVID staff meetings
• Staff are provided with regular training
and instruction as guidance changes
How is your service working with other
practices, and sectors, to promote
access to good oral health and deal
with any missed appointments?
• Appointment Book Management Policy
and Procedure
• Safeguarding Policy and Procedure
• Staying updated on guidance from the
BDA website and LDC newsletters
• Evidence of local arrangements with a
buddy practice
• Business Continuity Plan Policy and
Procedure
• Dental Neglect training with staff
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CARING
C1: How does the service ensure that people are treated with kindness, respect and compassion,
and that they are given emotional support when needed?
Potential Evidence
How have you adapted how you
support and engage with patients and
their families/loved ones (for example,
in the context of more remote working)?
• Video Consultations Policy and Procedure
• Feedback from patients and their relatives
and carers via email
• Google reviews
• Friends and Family Test
• Staff feedback questionnaires
• Dedicated email domain for patient advice
• Discuss how you have responded to
patient feedback and if you took any
action – give examples
• Triaging clinic daily
• Staff rota to reflect delegation of triaging
responsibilities
• Implementation of remote prescribing and
working with local Pharmacies
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C2: How does the service support people to express their views and be actively involved in
making decisions about their care, support and treatment as far as possible?
Potential Evidence
How do you support people to express their
views and actively involve them to make
decisions as far as possible?
• Consent Policy and Procedure
• Patient feedback
• Complaints, Suggestions and
Compliments Policy and Procedure
• Patient Involvement Policy and
Procedure
• Treatment Plan Policy and Procedure
• Give examples of how you have
responded to feedback or how you
de- escalated a complaint
• Discuss how you share this
information with the wider team
• Evidence of meeting minutes
• Evidence of staff training in
Complaints handling and ethics
• Complaints poster displayed in the
Practice and on social media/website
platforms
• Complaints leaflets available
• Details of Complaints Officer/Lead
• Discuss how complaints are logged
manually or electronically
• Examples of how you share any
actions taken from a
complaint/feedback to the patient
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RESPONSIVE
R1: How do people receive personalised care that is responsive to their needs?
Potential Evidence
How do you take into account patient
choice about how, when, where they
want to be seen?
• Consent Policy and Procedure
• Referral Policy and Procedure
• Accessible Information Standards Policy and
Procedure
• Patients with Communication Difficulties
Policy and Procedure
• Patient Involvement Policy and Procedure
• Mental Capacity Act (MCA) 2005 Policy and
Procedure
• When and how would you implement Gillick
Competency checks?
• Discuss the procedure on providing patients
with their treatment options, how is this
documented in the patient records?
• Describe and evidence the communication
methods to show how patients can make
decisions about their care and treatment
• Are information leaflets or videos available
to the patients? Do you direct them to online
resources?
• Are patients given ample time to think about
their options and discuss these with friends
and family?
• How do you document their final decision?
How do you ensure that people with
information and communication
needs are able to access
appointments and services in ways
that meet their needs?
• Dental Care Communication and
Information Policy and Procedure
• Access to Information Policy and Procedure
• Patients with Communication Difficulties
Policy and Procedure
• Describe how you help patients with a
Learning Disability to access appointments
• Provide examples of any adjustments made
for patients
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• Do you have a hearing loop? Braille leaflets?
Translation or interpreter services
available?
• Is there wheelchair access? A stairlift?
Disabled access WC? Ramps?
• Is the reception desk at a reasonable height
for wheelchair users and people with
dwarfism, what reasonable adjustments
have you made to accommodate less
able-bodied patients?
• Do you have appropriate lighting throughout
the premise for those with poor or limited
eyesight?
• Discuss how you would book a patient with
diabetes or severe dental phobia?
• Give an example of when you went above
and beyond to accommodate a patient with
additional needs?
• How would you accommodate a patient
who arrives to the practice and informs you
they are Transgender and wish to change
their name and pronouns on their records?
• Evidence staff training Evidence Practice
meeting minutes
Have you identified any barriers to
care provision, particularly for
patients with protected
characteristics? For example,
disabled or older people. If yes, what
actions have been taken to combat
them?
• Provide examples of issues you have
come across and how you have addressed
them
• Risk Assessment Policy and Procedure
• Individual Risk Assessments
• Black and Asian minority risk assessments
• Disability Access Audit
• How have you managed shielded patients
who have required urgent dental treatment?
• Referrals to UDCs
• Triaging procedures
• Referrals to Community Dental Services
• Management of urgent cancer referrals
• What adjustments have you made to how
you manage these patients?
• Discuss any training you have provided your
staff to recognize these patients
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R3: Can people access care and treatment in a timely way
Potential Evidence
How are you managing access to
services?
Do you have backlogs of activity and
long waiting times as a result of
coronavirus? How are you managing
this? What are your recovery plans?
• Appointment data from your clinical
system
• Waiting lists for patients part way
through treatment
• Running reports to reflect incomplete
course of treatment
• Cancellation code to reflect
COVID-19 as reason for cancelled
appointment for auditing purposes
• Prioritising outstanding treatments
based on need, urgency and patients
shielded status
• How will you work through any existing
blog?
• Provide examples of how you have
managed this thus far
• What hurdles have you overcome?
How are you ensuring that
high-risk/vulnerable patients and
pathways are being identified and
prioritised appropriately?
• Describe how you triage patients before
arranging face to face appointments to
ensure it is an essential journey and in line
with the patient pathways
• Describe how you have zoned your
diaries to allow for emergency clinics,
vulnerable or shielded patients to attend
• Describe how you ensure that staff are
aware of the appropriate pathways for
patients e.g. GOV.UK Guidance on
Shielding and Protecting People Who are
Clinically Extremely Vulnerable from
COVID-19 and COVID-19 infection
prevention and control guidance.
• Discuss how you have managed fallow time
or what provisions you have put in place to
mitigate the risk or reduce fallow time via
mechanical extraction
• Evidence staff training
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What are your arrangements to
follow-up and support patients whose
care and treatment was delayed due to
coronavirus? For example, patients with
non-coronavirus related issues.
• Describe how you manage waiting lists
for patients whose appointments were
postponed during the pandemic
• Describe your recovery plans
• Discuss the impact the coronavirus has
had on your practice and how you have
been managing appointments, with
60-minute fallow time, reduced surgeries
and staffing rota issues due to
self-isolation or infection
How are you ensuring equitable access
to appointments when they are needed,
especially for people with protected
characteristics and vulnerable groups?
For example, Trans people, people who
are housebound, people at the end of
their life (not relevant to online services)
• Appointment Book Management
Policy and Procedure
• Dental Care Communication and
Information Policy and Procedure
• Transgender Policy and Procedure
• Describe how these patients access
appointments
• Equality and Human Rights Policy and
Procedure
• Do you run a Domiciliary service? If so,
discuss arrangements in place
• FGDP Dementia friendly dentistry good
practice guidelines
• Safeguarding Policy and Procedure
• Updated Safeguarding training
• Mental Capacity assessments – give
examples
• Robust referral system in place to log,
track and follow up
How do you ensure that patients are
receiving appropriate types of
appointments to meet their needs?
• Appointment Book Management
Policy and Procedure
• Patient feedback
How do you ensure that people are able to
register with the practice? For example,
refugees, asylum seekers, migrants and
homeless people
• Equality and Diversity Policy and
Procedure
• Equality and Human Rights Policy and
Procedure
• Refer to GOV.UK Dental Health: Migrant
health Guide
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How is the service working with
partners to maintain and improve
access? (For example, third-party
providers, carer services, local
services such as ambulance service
etc.)
• Communication Policy and Procedure
• Management Meetings Policy and
Procedure
• Describe how you are providing NHS 111
appointments and liaising with the UDCs,
GPs and other dental professionals in your
field
• Give an example of when you may have
organised treatment via another allied
healthcare professional
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WELL LED
W3: Is there a culture of high-quality, sustainable care?
Potential Evidence
What actions are you taking to protect
and support the health, safety, and
wellbeing of staff, particularly those who
are high-risk for example, coronavirus
testing?
• Risk Assessments – e.g. for staff
(including Vulnerable Groups during
COVID-19) and Risk of Showing
Symptoms of Coronavirus
• Give examples of any reasonable
adjustments you have put in place
• Black and Asian Minority Groups risk
assessments
• Fit testing of FFP2/3 masks and RPE
• Lateral Flow tests – twice weekly
• Level 2 PPE
• On-going training as Government advice
and the science changes
• Updated Cross Infection and Prevention
guidelines
• Access to vaccination (voluntary)
• Furlough – high risk staff
• Discuss what your arrangements were and
how you accommodated your staffing
needs during the initial lockdown
How do you promote equality and diversity,
and check that staff feel supported,
respected, and valued?
• Equality and Diversity Policy and
Procedure
• Staff Retention Policy and Procedure
• Quality Meetings Policy and Procedure
• Management Meetings Policy and
Procedure
• Staff feedback from surveys, appraisals,
one-to-one meetings, and opportunistic
discussions
• PDP meetings
• Regular 1-2-1 catchups with staff
• Training Policy and Procedure
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What training and support is available for
staff using new technology to deliver
care? (Not relevant to online services)
• Training Policy and Procedure
• Home Working Policy and Procedure
• Mock Inspections
• Maintain open communication and
review staff needs – training analysis
• Describe how staff are using and
adapting to different ways of using
technology to deliver care
How are you supporting staff who work
remotely and how are you assessing
them?
• Home Working Policy and Procedure
• Communication Policy and Procedure
• Describe how you keep in touch with
staff working from home
W5: Are there clear and effective processes for managing risks, issues, and performance?
Potential Evidence
Has your business/operating model
changed since the pandemic? If so, how,
and what has been the impact on staff
and people who use your services?
• Pandemic Policy and Procedure
• Quality audits
• Evidence of good governance i.e. meetings,
action plans and lessons learnt
How do you assure yourself that you are
providing a safe service? For example,
regular audits and increased supervision
etc.
• Clinical Governance Policy and
Procedure
• Audit Policy and Procedure
• Quality Meetings Policy and Procedure
• Evidence actions and learning from any
audits and meetings, with examples of how
this has driven improvement in the service
How are you monitoring business risks
and issues, and what actions are you
taking to respond to them?
• Risk Management Policy and Procedure
• Business Continuity Policy and
Procedure
• Following advice from NHS England CDO,
FGDP, BDA etc. and updating SOP to
reflect the changes
• Implementing changes and providing
staff with adequate training to carry out
any new roles and responsibilities
• Staff and patient feedback
• Regular management and practice
meetings
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What are the arrangements for
business continuity? For example,
arrangements for diverting calls,
contingency planning for staff
shortages/outbreak onsite, changes
made in light of coronavirus. How are
you flexing the service/models of
care to adapt to changing
circumstances, including second
wave of coronavirus?
• Business Continuity Policy and
Procedure
• Describe how you have reviewed your
Business Continuity Plan, what
adjustments you have made and what
lessons you have learned to put things in
place for any further waves of the
pandemic
How are you working with partners to
review and update local pathways?
• Describe how you are working with the
CDO, NHSE, BDA, FGDP, SDCEP, local
Practices and other care providers
How do you ensure oversight and
governance of care provided by external
staff who are working with your patients?
For example, Agency or locum staff
• Clinical Governance Policy and
Procedure
• Locum Policy and Procedure
• Agency Staff Policy and Procedure
• Supervision Policy and Procedure
What are your arrangements for X-ray
equipment at the Practice and radiation
protection?
• HSE registration evidence
• RPA arrangements in place
• Regular audits – evidence available
• Dosimeter badges
• Radiography and Radiation Protection
Policy and Procedure
• What are your new procedures for taking
and developing X-rays during an AGP
procedure?
• Do you have a runner or buddy staff
member processing X-rays?
• Have they been adequately trained? Is
this documented?
• How have you maintained equipment
and servicing during this time?
• Dental Equipment Maintenance Policy
and Procedure
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W8: Are there robust systems and processes for learning, continuous improvement, and
innovation?
Potential Evidence
What systems are in place to support
people (staff/people who use your services
and their families/carers) to speak up and
raise concerns?
• Complaints, Suggestions and
Compliments Policy and
Procedure
• Whistleblowing Policy and Procedure
• Duty of Candour Policy and Procedure
• GDC Policy and Procedure
• Posters on display
• What information is available to patients
and how are they made aware of this?
• Staff training – evidence on how to
handle complaints and feedback
• Encourage open door policy for staff to
raise concerns
• Who do staff raise concerns with?
• Give an example...
• Regular staff meetings – meeting
minutes
How do you support people to provide
feedback?
• Staff surveys
• Patient surveys
• Patient Participation Group
• Friends and Family Test
• Online feedback via the Practice website
• Google review
• Social media reviews
• Encourage honest feedback – and share
changes implemented as a result of
feedback back to patients on a regular
basis
• Maintain open communication with
patients and staff