Trinity Dental Surgery

Updated 9 January 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.

This inspection took place on 18 October 2016 and was led by a CQC inspector and supported by a specialist dental advisor. Prior to the inspection, we reviewed information we held about the provider. We informed NHS England area team that we were inspecting the practice and we did not receive any information of concern from them. We asked the practice to send us some information that we reviewed. This included the complaints they had received in the last 12 months, their latest statement of purpose, and the details of their staff members including proof of registration with their professional bodies.

During our inspection we toured the premises; we reviewed policy documents and staff records and spoke with five members of staff, including the principal dentist. We looked at the storage arrangements for emergency medicines and equipment. We were shown the decontamination procedures for dental instruments and the computer system that supported the 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 9 January 2017

We carried out an announced comprehensive inspection on 18 October 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

Trinity Dental Surgery has three dentists who work part time, a part time hygienist, one qualified dental nurse who is registered with the General Dental Council (GDC) and two trainee dental nurses. The practice’s opening hours are 8.30am to 5.30pm on Monday, Tuesday and Thursday, 8.30am to 1pm on Wednesday and 8.30am to 3.30pm on Friday.

Trinity Dental Surgery provides NHS dental treatment for adults and children. The practice has two dental treatment rooms on the ground floor and one dental treatment room on the first floor. There is a separate decontamination room for cleaning, sterilising and packing dental instruments. There was also a reception and waiting area on the ground floor.

The principal dentist is registered with the Care Quality Commission (CQC) as an individual. 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.

Before the inspection we sent Care Quality Commission comments cards to the practice for patients to complete to tell us about their experience of the practice and during the inspection we spoke with patients. We received feedback from 19 patients who provided an overwhelmingly positive view of the services the practice provides. All of the patients commented that the quality of care was good and staff were professional and knowledgeable.

Our key findings were

• Systems were in place for the recording and learning from significant events and accidents.
• There were sufficient numbers of suitably qualified staff to meet the needs of patients.
• Patients were treated with dignity and respect.
• The practice was visibly clean and well maintained.
• Infection control procedures were in place with infection prevention and control audits being undertaken on a three monthly basis. Staff had access to personal protective equipment such as gloves and aprons.
• There was appropriate equipment for staff to undertake their duties, and equipment was well maintained.
• The provider had emergency medicines in line with the British National Formulary (BNF) guidance for medical emergencies in dental practice.
• Staff had been trained to deal with medical emergencies.
• The appointment system met the needs of patients and waiting times were kept to a minimum.
• The practice was well-led and staff felt involved and worked as a team.
• Governance arrangements were in place for the smooth running of the practice and there was a structured plan in place to audit quality and safety beyond the mandatory audits for infection control and radiography.

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

• Review the recruitment procedures and protocols to ensure that all pre-employment information is obtained in line with Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

• Review the practice’s fire safety procedures and ensure that regular checks are made of all firefighting equipment including emergency lighting, that all staff are involved in fire drills on a regular basis and that the practice undertakes and records details regarding a robust fire risk assessment.