Updated 15 November 2019
We carried out this announced inspection on 29 October 2019 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
Muirhead Associates is in the Shipley and provides private treatment for adults and NHS treatment for children.
There is level access for people who use wheelchairs and those with pushchairs. The practice has five surgeries with two based on the ground floor. There is a dedicated car park within the grounds of the practice and local transport facilities are available nearby.
The dental team includes four dentists, three dental hygienists, six dental nurses, the practice manager and two receptionists.
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 nine CQC comment cards filled in by patients. We also received 27 web-based comment cards. All comments received were very positive about the care and treatment provided at the practice.
During the inspection we spoke with two dentists, three dental nurses, a receptionist and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday 8.30am-7pm, Tuesday, Wednesday, Thursday and Friday 8.30am-5.30pm.
Our key findings were:
- The practice appeared clean and well maintained.
- The provider had infection control procedures which reflected published guidance.
- Staff knew how to deal with emergencies.
- The provider had effective systems in place to help them manage risk to patients, with the exception of fire safety, legionella and a lone working risk assessment for the cleaner.
- The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The provider had thorough 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.
- Staff provided preventive care and support patients to ensure better oral health.
- The appointment system took account of patients’ needs.
- The provider had effective leadership and culture of continuous improvement.
- Staff felt involved and supported and worked well as a team.
- The provider asked staff and patients for feedback about the services they provided.
- The provider dealt with complaints positively and efficiently.
- The provider had suitable information governance arrangements.
There were areas where the provider could make improvements. They should:
- Improve the security of NHS prescription pads in the practice and ensure there are systems in place to track and monitor their use.
- Take action to implement any recommendations in the practice's Legionella risk assessment, taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.’ In particular, undertake water temperature checks and reviews of the water system.
- Take action to implement any recommendations in the practice's fire safety risk assessment and ensure ongoing fire safety management is effective.
- Improve the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance PHE-CRCE-023 on the safe use of Hand-held Dental X-ray Equipment.