Updated 6 July 2018
We carried out this announced inspection on 29 May 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a CQC inspector who was supported by a specialist dental adviser.
To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:
• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well-led?
These questions form the framework for the areas we look at during the inspection.
Our findings were:
Are services safe?
We found that this practice was providing safe care in accordance with the relevant regulations.
Are services effective?
We found that this practice was providing effective care in accordance with the relevant regulations.
Are services caring?
We found that this practice was providing caring services in accordance with the relevant regulations.
Are services responsive?
We found that this practice was providing responsive care in accordance with the relevant regulations.
Are services well-led?
We found that this practice was providing well-led care in accordance with the relevant regulations.
Background
Weston Cottage Dental Practice is in Thames Ditton and provides private treatment to adults and children.
There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice.
The dental team includes two dentists, two dental nurses, one dental hygienist, and one receptionist. The practice has two treatment rooms.
The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.
On the day of inspection we collected 40 CQC comment cards filled in by patients.
During the inspection we spoke with one dentist, one dental and nurse one receptionist. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open: Monday to Thursday 08.30 to 17.00 and Friday 08.30 to 13.00
Our key findings were:
- The practice appeared clean and well maintained.
- The practice staff had infection control procedures which reflected published guidance.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- The practice had systems to help them manage risk.
- The practice staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
- The practice had staff recruitment procedures.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
- The practice was providing preventive care and supporting patients to ensure better oral health.
- The appointment system met patients’ needs.
- The practice had effective leadership and culture of continuous improvement.
- Staff felt involved and supported and worked well as a team.
- The practice asked staff and patients for feedback about the services they provided.
- The practice staff dealt with complaints positively and efficiently.
- The practice staff had suitable information governance arrangements.
There were areas where the provider could make improvements. They should:
- Review the practice’s protocols to ensure audits of radiography, patient notes and antimicrobial prescribing and control are undertaken at regular intervals to improve the quality of the service. Practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.
- Review the practice’s protocols for the use of rubber dam for root canal treatment taking into account guidelines issued by the British Endodontic Society. The practice need to develop a policy which includes how and where to record if a rubber dam cannot be used.
- Review the practice's recruitment policy and procedures to ensure accurate, complete and detailed records are maintained for all staff.
- Review the practice's recruitment procedures to ensure that appropriate checks are completed prior to new staff commencing employment at the practice.
- Review the practice's responsibilities to take into account the needs of patients with disabilities and to comply with the requirements of the Equality Act 2010.
- Review the practice's current performance review systems and have an effective process established for the on-going assessment and supervision of all staff.
- Review the practice’s arrangements for ensuring good governance and leadership are sustained in the longer term.