St John's Surgery - Windermere

Updated 11 February 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

This inspection took place on the 8 January 2016. The inspection team consisted of a Care Quality Commission (CQC) inspector and a dental specialist advisor.

Prior to the inspection we reviewed information we held about the provider. We informed NHS England area team / Healthwatch that we were inspecting the practice; however we did not receive any information of concern from them.

We also reviewed information we asked the provider to send us in advance of the inspection. This included their latest statement of purpose describing their values and their objectives, a record of any complaints received in the last 12 months and details of their staff members, their qualifications and proof of registration with their professional bodies.

During the inspection we toured the premises and spoke with five practice staff including, the principal dentist, a dental hygienist, two dental nurses and the practice manager. To assess the quality of care provided we looked at practice policies and protocols and other records relating to the management of the service.

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 therefore formed the framework for the areas we looked at during the inspection.

Updated 11 February 2016

We carried out an announced comprehensive inspection on 8 January 2016 to ask the practice the following key questions; Are services safe, effective, caring, responsive and well-led?

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

The dentist offers both NHS and private dental care services to patients of all ages. The services provided include preventative advice and treatment and routine and restorative dental care. Visiting specialists carry out dental implant procedures and provide conscious intravenous (IV) sedation for nervous patients. The practice has two principal dentists, one associate dentist, four dental hygienists and seven qualified dental nurses; in addition to a practice manager.

The practice has four treatment rooms, a reception area, separate waiting room and a decontamination room. The building is single storey and all areas are easily accessible throughout the building. The practice is open on Monday to Friday from 9.00am until 5.00pm. The surgery is piloting a Saturday opening from 09:00am -12 noon and late evening appointments on one evening (Tuesdays or Wednesday) every two weeks from 5:30pm to 8pm.

We viewed 49 CQC comment cards that had been left for patients to complete, prior to our visit, about the services provided. In addition we spoke with two patients on the day of our inspection. We reviewed patient feedback gathered by the practice through patient surveys and comments from the NHS Friends and Family Test. Feedback from patients was overwhelmingly positive about the care they received from the practice. They commented staff were caring and respectful and that they had confidence in the dental services provided. Patients told us they had no difficulties in arranging a convenient appointment and that staff put them at ease and listened to their concerns.

Our key findings were:

• The practice had systems to assess and manage risks to patients, including infection prevention and control, health and safety and the management of medical emergencies.
• The practice carried out oral health assessments and planned treatment in line with current best practice guidance, for example from the Faculty of General Dental Practice (FGDP). Patient dental care records were detailed and showed on-going monitoring of patients’ oral health.
• Patients commented they felt involved in their treatment and that it was fully explained to them.

• Patients were able to make routine and emergency appointments when needed. There were clear instructions for patients regarding out of hours care.

• The dental practice had effective clinical governance and risk management structures in place. There were systems to monitor and continually improve the quality of the service; including through a programme of clinical and non-clinical audits.
• There were clearly defined leadership roles within the practice and staff told us they felt well supported and comfortable to raise concerns or make suggestions.

There were areas where the provider could make improvements and should:

• Review the practice's recruitment policy and procedures to ensure character references for new staff as well as proof of identification are requested and recorded suitably.
• Review the safe management and monitoring of NHS prescriptions pads.
• Put an adult safeguarding policy in place and implement a procedure.