We carried out this announced inspection on 18 September 2017 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.
We told the NHS England area team and Healthwatch that we were inspecting the practice. They did not provide any information.
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 this practice was providing safe care in accordance with the relevant regulations.
Are services effective?
We found this practice was providing effective care in accordance with the relevant regulations.
Are services caring?
We found this practice was providing caring services in accordance with the relevant regulations.
Are services responsive?
We found this practice was providing responsive care in accordance with the relevant regulations.
Are services well-led?
We found this practice was not providing well-led care in accordance with the relevant regulations.
Background
Barley Mow Dental Practice is in Malmsbury and provides private treatment to patients of all ages and NHS treatment to children only.
There is level access for patients who use wheelchairs and pushchairs. Car parking spaces can be on roads near the practice. There are no parking spaces identified for patients with disabled badges.
The dental team includes three dentists, six dental nurses, three dental hygienists, and three receptionists. The practice has three 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 48 CQC comment cards filled in by patients and spoke with two other patients. This information gave us a positive view of the practice.
During the inspection we spoke with two dentists, three dental nurses, and two receptionists. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
- Monday – Wednesday 8.30am – 5.15pm
- Thursday 08.30am – 6.45pm Friday 8.30am – 1.00pm
It is closed at weekends and out of hours information is available on the website.
Our key findings were:
- The practice appeared clean and well maintained.
- The practice 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 but they were not always operated effectively.
- The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
- The practice recruitment procedures did not meet the legislative requirements for the safe recruitment of staff.
- 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 appointment system met patients’ needs.
- The practice had mostly effective leadership but it did not ensure staff completed all required continuing professional development through appraisal.
- 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 dealt with complaints positively and efficiently.
We identified regulations the provider was not meeting. They must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
- Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
Full details of the regulations the provider was not meeting are at the end of this report.
There were areas where the provider could make improvements. They should:
- Review their responsibilities with regard to the Control of Substances Hazardous to Health (COSHH) Regulations 2002 and ensure all documentation including product sheets are available and staff understand how to minimise risks associated with the use and handling of these substances.
- Review its responsibilities to respond to the needs of patients with disability and the requirements of the Equality Act 2010.