28th March 2017
During a routine inspection
We carried out an announced comprehensive inspection on 28th March 2017 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
Lovat House Dental Practice is located in the centre of Cheltenham and provides private treatment to adults and NHS treatment to children. The practice consists of four treatment rooms, toilet facilities for patients and staff, a reception area and waiting area.
The practice offers routine examinations and treatment. There is one dentist, who is also the registered provider, two dental hygienists, one dental nurse and two receptionists. This provider shares the facilities in the practice with two other dentists who are also registered separately as providers.
The practice’s opening hours are
Monday to Thursday 9am to 1pm and 2pm to 5pm
Alternate Fridays 9am to 12noon
Out of hours the three dentists took turns to be on-call and patients were directed to phone the dentist on-call.
We carried out an announced, comprehensive inspection on 28th March 2017. The inspection was led by a CQC inspector who was accompanied by a specialist dental advisor.
For this inspection 6 people provided feedback to us about the service. Patients were positive about the care they received from the practice. They were complimentary about the service offered, which they said was excellent. They told us that staff were kind, helpful, caring and respectful and the practice was clean and hygienic.
Our key findings were:
• Safe systems and processes were in place, including a lead for safeguarding.
• Staff recruitment needed to be improved because relevant checks had not been conducted for the most recent person employed. Staff received relevant training.
• The practice had ensured that some risk assessments were in place. We found that there was no Legionella risk assessment had the fire risk assessment had not been carried out by an appropriately qualified person.
• The clinical equipment in the practice was appropriately maintained. The practice appeared visibly clean throughout although parts of the surgery were cluttered.
•The process for decontamination of instruments followed relevant guidance.
• The practice maintained appropriate dental care records and patients’ health details were updated. We found that some clinical details were not always recorded.
• Patients were provided with health promotion advice to promote good oral care.
• Consent was obtained for dental treatment.
• The dentist was aware of the process to follow when a person lacked capacity to give consent to treatment.
• All feedback that we received from patients was positive; they reported that it was a caring, respectful and helpful service.
• There were arrangements for governance at the practice such as systems for auditing infection control, radiographs and patient records.
There were areas where the provider could make improvements and should:
- Review the procedure for dealing with accidents so that it includes a record of the investigation of the accident and of any follow up action needed.
- Review the recruitment procedures to ensure that Disclosure and Barring Service (DBS) and references are obtained before new staff start work in the practice in line with current guidance.
- Review the arrangements for support to staff to make sure all staff receive regular appraisals and personal development plans.
- Review the arrangements for fire safety including the fire risk assessment.
- Review the arrangements for prevention of Legionella.
- Review the layout of the surfaces and cupboards in the surgery and the room with the X-ray developer to ensure they are free from clutter and are easy to clean.
- Review the storage of paper records to make sure that patient records are stored securely to ensure confidentiality.
- Review the arrangements for communication to include a hearing loop for patients with a hearing impairment and access to a translation service for people whose first language is not English.
- Review the arrangements for recording patient information to make sure that a Basic Periodontal Examination (BPE) is conducted at each check-up appointment and the scores are always recorded.
- Review the arrangements for obtaining patient feedback to make sure questionnaires are reviewed at regular intervals and improvements are identified as a result of feedback.
- Review the arrangements for auditing to make sure that the infection control audits are more in depth and include action plans and learning outcomes.