Updated 28 November 2019
We carried out this announced inspection on 16 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
Avondale House Dental Surgery is in Rugeley, Staffordshire and provides NHS and private dental treatment to adults and children.
There is ramped access for people who use wheelchairs and those with pushchairs. Car parking spaces, including some for blue badge holders, are available in local pay and display car parks near the practice.
The dental team comprises of six dentists (including the practice owner), 10 dental nurses some of whom cover reception duties (six of whom are trainee dental nurses) and the practice manager. The practice has five treatment rooms.
The practice is owned by a company and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run. The registered manager at Avondale House Dental Surgery is the practice owner.
We sent 50 comment cards in advance of our visit to the practice for patients to complete. On the day of inspection, we collected 22 CQC comment cards that had been filled in by patients. This represented an 44% response rate.
During the inspection we spoke with four dentists including the practice owner and nine dental nurses. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday to Wednesday from 9am to 6pm.
Thursday from 9am to 5pm.
Friday from 9am to 4pm.
Our key findings were:
- The practice appeared clean and well maintained.
- The provider had infection control procedures which reflected published guidance. We found that the infection prevention and control audit was inaccurate to our findings and that there was no analysis, action plan or shared learning to drive improvement.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available with the exception of the defibrillation pads which were out of date. These were ordered on the day of our inspection.
- The provider had some systems to help them manage risk to patients and staff. However, systems pertaining to maintenance of electrical appliances and substances hazardous to health were not effective.
- 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 supported patients to ensure better oral health.
- The appointment system took account of patients’ needs.
- The provider had identified that support was required with the practice leadership and had recruited a practice manager in August 2019.
- 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 practice's systems for assessing, monitoring and mitigating the various risks arising from the undertaking of the regulated activities. In particular ensuring that annual visual checks are completed for portable appliances and that five yearly fixed wire testing is completed in accordance with published guidance.
- Take action to ensure audits of infection prevention and control are completed accurately to improve the quality of the service. The practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.
- Improve the practice's processes for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken for all materials and substances.