Archived: Menlove Dental Surgery

We carried out an announced comprehensive inspection on 17 March 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 not providing well-led care in accordance with the relevant regulations.

Background

Menlove Dental Practice is located in a residential suburb and comprises a reception, waiting room, two treatment rooms, an office and staff room on the ground floor, and three treatment rooms, a decontamination room and an X-ray room on the first floor. Parking is available on nearby streets. The practice is accessible to patients with disabilities, impaired mobility and to wheelchair users.

The practice provides general dental treatment to patients of all ages on an NHS or private basis.

The practice is open Monday to Thursday 9.00am to 5.30pm and Friday 9.00am to 4.30pm and is staffed by a practice manager, six dentists, three hygienists, four receptionists, one of whom is a trainee, and ten dental nurses, two of whom are trainees.

The principal dentist 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.

We received feedback from 47 people on CQC comment cards and spoke to four patients during the inspection about the services provided. Every comment was positive about the staff and the service. Patients commented that they found the staff efficient, helpful, kind and and caring. They said that they were always given good explanations about dental treatment and that dentists listened to them.

Our key findings were:

• There was a sufficient number of suitably qualified staff to meet the needs of patients.
• Staff had been trained to deal with medical emergencies and the recommended emergency medicines and equipment were available and appropriately monitored.
• Staff had received safeguarding training and knew the process to follow to raise any concerns.
• Patients’ needs were assessed and care and treatment were delivered in accordance with current legislation, standards and guidance.
• Patients received explanations about their proposed treatment, costs, benefits and risks and were involved in making decisions about it.
• Patients were treated with kindness, dignity and respect and their confidentiality was maintained.
• Patients commented that they were always able to obtain routine and emergency appointments and waiting times were kept to a minimum.
• Services were planned and delivered to meet the needs of patients and reasonable adjustments were made to enable patients to receive their care and treatment.
• The practice had a formal system in place to actively seek the views of people using the service and used this feedback to help them improve.
• The practice recorded accidents and complaints but did not record and analyse significant events.
• The practice received safety alerts but we did not see evidence of action taken in relation to these.
• Improvements were needed to the general condition and cleanliness of the practice.
• Dental X-ray equipment had not been tested within the recommended time interval and one X-ray machine was damaged.
• Some staff lacked training for undertaking their roles and support with professional development.
• Governance systems and processes were in place for the running of the practice; however several were inadequate or were not operating effectively.
• Policies, procedures and risk assessments were not reviewed and updated in line with current legislation and guidance.
• The provider did not share learning from complaints, events, concerns and audits to encourage improvement.

We identified regulations that were not being met and the provider must:

• Ensure that the practice is in compliance with its legal obligations under the Ionising Radiation Regulations 1999 and the Ionising Radiation (Medical Exposure) Regulations 2000 in relation to the maintenance and testing of X-ray equipment.
• Ensure the practice’s infection control procedures and protocols are suitable having due regard to guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance, in relation to maintaining standards of hygiene appropriate for the service.
• Ensure systems or processes are established and operated effectively to ensure compliance with regulations 4 to 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, specifically in relation to systems for recording of significant events, cleaning, recruitment, reviews of policies and risk assessments. The provider must also ensure systems are established to evaluate and improve the service.

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

• Review the training, learning and development needs of individual staff members and establish an effective process for the on-going assessment and supervision of all staff.
• Review methods to support communication to staff about the quality and safety of services.
• Review the recording of complaints to ensure verbal complaints are captured and actions and learning points are recorded.
• Implement an archived paper records storage facility which meets health and safety and fire regulations in accordance with the Department of Health’s code of practice for records management (NHS Code of Practice 2006) and other relevant guidance about information security and governance.