Pagham Dental Surgery

Updated 21 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 was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The inspection was carried out on 8 December 2016 by a CQC inspector who was supported by a specialist dental advisor.

We informed NHS England area team that we were inspecting the practice; however we did not receive any information of concern from them.

During the inspection, we spoke with the principle dentist, a dental nurse and a receptionist who performs a dual role as a dental nurse. We reviewed policies, procedures and other documents. We also reviewed 39 comment cards that we had left prior to the inspection, for patients to complete, about the services provided at the practice. We obtained the views of five patients on the day of the inspection. We carried out a tour of the practice observing the decontamination procedures for dental instruments. We looked at the storage of emergency medicines and equipment. We were shown the systems which supported patients’ dental care records.

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 21 March 2017

We carried out an announced comprehensive inspection on 8 December 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

Pagham Dental Surgery is located within a parade of shops in the small town of Pagham. The practice provides private and NHS general dentistry to approximately 2000 patients. The majority of work is carried out under the NHS. The practice comprises of two recently refurbished surgeries, a separate decontamination room and a small reception and patient waiting area.   

The practice employs a principle dentist, a hygienist, a dental therapist and one qualified nurse. One receptionist is also a qualified nurse and provides cover when needed.   

The practice is open Monday to Thursday 9am to 5pm. A hygienist is available on Friday from 9am to 4pm and appointments for the dentist on Friday are by appointment only. Out of hours is provided by the Surrey and Sussex area team, the contact details of which are available on the practice answerphone when the practice is closed.  

The inspection took place over one day and was carried out by a CQC inspector and a dental specialist advisor.  

The principle dentist 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 39 completed Care Quality Commission (CQC) comment cards and obtained the views of five patients on the day of the inspection. Patients commented on the thorough and very good treatment that they received by staff that were very caring and polite. Patients told us that they were made to feel welcome and that reception staff were helpful. 

Our key findings were:   

·         The practice appeared visibly clean, was bright and clutter free.

·         Staff were welcoming, professional and kind.

·         Staff had made all reasonable adjustments to enhance access to the practice.

·         There was appropriate equipment for staff to undertake their duties. All equipment was well maintained.

·         Staff had been trained to deal with medical emergencies and emergency medicines and equipment were readily available as per British National Formulary, the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.

·         Patients were able to make routine and emergency appointments when needed.

·         Infection control procedures protocols were suitable giving due regard to 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’.

·         Clinical staff had the necessary skills to carry out their duties in line with the requirements of their professional registration.

·         Governance arrangements were in place for the smooth running of the practice.

·         Information from 39 completed Care Quality Commission (CQC) comment cards gave an entirely positive picture of a friendly and caring service.

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

·         Review the practice’s recruitment policy and procedures to ensure that the arrangements are in line with Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 to ensure necessary employment checks are in place for all staff and the required specified information in respect of persons employed by the practice is held.

·         Review the protocols and procedures to ensure staff are up to date with their mandatory training and Continuing Professional Development in accordance with the requirements of the General Dental Council

·         Review the practice record keeping policy to ensure that dental care records are maintained appropriately giving due regard to guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.

·         Review the use of the Friends and Family Test and consider displaying the results for patients in accordance with the guidelines provided by the NHS.