22 April 2015
During a routine inspection
We carried out an announced comprehensive inspection on 22 April 2015. CQC inspected the practice on 5 April 2014 and identified areas thet needed improvement in regards to infection prevention and control. We asked the provider to make improvements regarding this breach and asked the provider to submit an action plan on how they intended to make improvements. We checked these areas as part of this comprehensive inspection and found that they were resolved.
The practice has one dentist who is also 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.
The dentist is supported by an associate dentist who works part time and three dental nurses who also work as receptionists.
The practice provides primary dental services to mainly NHS patients. The practice is open Monday to Friday between the hours of 9.15am and 5.15pm. The practice is also open from 9am to 1pm on Saturdays.
We spoke with one patient during the inspection. They told us that they were very satisfied with the services provided, that the dentists provided them with clear explanations about their care and treatment, that costs were clear and that all staff treated them with dignity and respect.
We viewed CQC comment cards that had been left for patients to complete, prior to our visit, about the services provided. There were 11 completed comment cards and all of them reflected positive comments about the staff and the services provided. Patients commented that the practice was clean and hygienic, they found it easy to book an appointment and they found the quality of the dentistry to be very good. They said explanations were clear and that the staff were kind, caring and reassuring. Patients also commented positively that there was always a dentist available when urgent treatment was required.
We found that this practice was providing safe, effective, caring, responsive and well-led care in accordance with the relevant regulations.
Our key findings were:
- The practice had a system in place to record significant events, safety issues and complaints and to cascade learning to staff.
- Staff had received safeguarding training and knew the processes to follow to raise any concerns.
- There were sufficient numbers of suitably qualified staff to meet the needs of patients
- Staff had been trained to handle emergencies and appropriate medicines were readily available.
- Infection control procedures were robust and staff were able to demonstrate how they followed the published guidance.
- Patient’s care and treatment was planned and delivered in line with evidence based guidelines, best practice and current legislation.
- Patients received clear explanations about their proposed treatment, costs, benefits and risks and were involved in decisions about it.
- Patients were treated with dignity and respect and confidentiality was maintained.
- The appointment system met the needs of patients and waiting times were kept to a minimum.
- The practice staff felt involved and worked as a team.
- There was a range of clinical and non-clinical audits to monitor the quality of services.
- The practice sought feedback from patients about the services they provided.
There were areas where the provider could make improvements and should:
- Ensure a business continuity plan is developed and has a comprehensive process for recovering from unexpected events that threaten the stability of the practice.
- Review the practice’s protocols and procedures for promoting the maintenance of good oral health giving due regard to guidelines issued by the Department of Health publication ‘Delivering better oral health: an evidence-based toolkit for prevention’.
- Have arrangements in place to provide access to translation services.
- Ensure all audits have learning points documented learning points of audits are carried out to demonstrate improvement.
- Ensure feedback received from patients is regularly analysed and responded to appropriately.