Bishopthorpe Dental Centre

Updated 25 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 registered provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The inspection was carried out on 12 January 2016 and was led by a CQC Inspector and a specialist advisor.

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

The methods that were used to collect information at the inspection included interviewing staff, observations and reviewing documents.

During the inspection we spoke with a dentist, a dental hygienist and three dental nurses. We saw policies, procedures and other records relating to the management of the service. We reviewed 20 CQC comment cards that had been completed.

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 25 February 2016

We carried out an announced comprehensive inspection on 12 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 Thorpe Dental Group operates Bishopthorpe Dental Centre. The service is located on Sim Balk Lane, York, North Yorkshire. A full range of dental services can be provided including private and children’s NHS treatments. The practice has wheelchair access and parking is available at the rear of this dental centre for people to use. The practice offers a variety of dental care plans where patients pay a monthly subscription and receive a discount off treatment and includes an examination every six months and a hygienist visit at varying intervals.

The practice currently has one dentist, a practice manager, two dental hygienists, five dental nurses (one of whom is a trainee).

Both surgeries are located on the ground floor. There is also a reception area, waiting area and a decontamination room.

The practice is open:

Monday – Friday 09:00 – 13:00 & 14:00 – 17:00.

On the day of inspection we received 20 CQC comment cards providing feedback and spoke with two patients The patients who provided feedback were positive about the care and treatment they received at the practice. They told us they were involved in all aspects of their care and were very pleased with the service. They found the staff to be friendly, curious, were efficient and caring and they were treated with dignity and respect in a clean and tidy environment.

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.

Our key findings were:

• Staff had been trained to manage medical emergencies.
• Infection prevention and control procedures were in accordance with the published guidelines.
• Patients’ care and treatment was planned and delivered in line with evidence based guidelines, best practice and current regulations.
• Patients were treated with dignity and respect and confidentiality was maintained.
• The appointment system met patients’ needs.
• Governance arrangements were in place for the smooth running of the practice; however the practice did not have a structured plan in place to audit quality and safety beyond the mandatory audits for infection control and radiography. They planned to establish a more detailed system for this.

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

• Review the protocol for receiving, sharing and acknowledging alerts by e-mail from the Medicines and Healthcare products Regulatory Agency (MHRA), the UK’s regulator of medicines, medical devices and blood components for transfusion, responsible for ensuring their safety, quality and effectiveness.
• Record fridge temperatures where dental materials are stored.
• Review the practice’s process for the auditing of various aspects of the service, such as infection prevention and control and X-rays so they are undertaken at regular intervals to help improve the quality of service. The practice should also ensure all audits have documented learning points so the resulting improvements can be demonstrated.
• Review the practice's recruitment policy and procedures so they are suitable and the recruitment 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.