Mansion House Dental Practice

Updated 6 March 2017

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 owner was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The inspection took place on 18 January 2017. It was led by a CQC inspector and supported by a dental specialist advisor.

We informed NHS England area team that we were inspecting the practice; we did not receive any information of concern from them. We also reviewed information held by CQC about the practice and no concerns were identified.

During the inspection, we spoke with the owner of the practice and two dental nurses. We reviewed policies, protocols, certificates and other documents as part of the inspection. We also had a look around the building.

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 6 March 2017

We carried out an announced comprehensive inspection on 18 January 2017 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

Mansion House Dental Practice is located in the centre of Ormskirk and provides predominantly private treatment plans for patients and a limited amount of NHS treatments. All patient facilities, including surgeries are located on the ground floor. Two dentists, a dental hygienist, three dental nurses and a receptionist work at the practice. There is parking and wheelchair access at the back of the building. Opening times are weekdays from 8.30am until 5.00pm with a late opening until 7.00pm on Tuesdays.

The practice owner is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is run.

We reviewed 19 CQC comment cards on the day of our visit and spoke with three patients during the inspection. Patients spoke highly of the staff and the standard of care provided by the practice. Patients commented that they felt involved in all aspects of their care and found the staff to be helpful, respectful, and friendly, and said they were treated in a clean and tidy environment.

Our key findings were:

• The practice was well organised, visibly clean and free from clutter.
• An infection prevention and control policy was in place. Sterilisation procedures followed Department of Health guidance.
• The practice had systems for recording incidents and accidents.
• The practice had a safeguarding policy and staff were aware on how to escalate safeguarding issues for children and adults should the need arise.
• Staff received annual medical emergency training. Equipment for dealing with medical emergencies reflected guidance from the resuscitation council (UK).
• Dental professionals provided treatment in accordance with current professional guidelines.
• A process was established to seek patient feedback about the service.
• Patients could access urgent care when required.
• Dental professionals were maintaining their continued professional development (CPD) in accordance with their professional registration.
• Complaints were dealt with in an efficient and sensitive manner.
• The practice was actively involved in promoting oral health.
• Recruitment checks were not complete for all staff.
• The temperature of sentinel taps (nearest and furthest hot and cold taps from the water distribution source) was not being checked as frequently as it should.
• A medicine was being dispensed at the practice but was not being dispensed to patients in the manufacturer’s original packaging complete with the patient information leaflet.
• Staff were not aware of a translation service should the need arise.

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

• Review the current Legionella risk assessment, including the monitoring and recording of water temperatures, giving due regard to the guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.
• Review the process for monitoring equipment requiring decontamination, in particular the dental chairs and stools, taking into account the guidelines issued by the Department of Health - Health Technical Memorandum 01-05.
• Review the practice's recruitment policy and procedures to ensure appropriate recruitment checks are undertaken for staff.
• Review the practice’s protocols for medicines management and ensure all medicines are managed and administered safely and securely.
• Review the access to an interpreter service for patients who do not speak English as their first language.