Background to this inspection
Updated
4 May 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 registered provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.
The inspection took place on 30 March 2017 and was led by a CQC Inspector assisted by a second CQC Inspector.
Prior to the inspection we asked the practice to send us some information which we reviewed. This included details of complaints they had received in the last 12 months, their latest statement of purpose, and staff details, including their qualifications and professional body registration number where appropriate. We also reviewed information we held about the practice.
We informed the NHS England Cheshire and Merseyside area team that we were inspecting the practice. We did not receive any information of concern from them.
During the inspection we spoke to the practice manager, two dentists, dental nurses and receptionists. We reviewed policies, protocols and other documents and observed procedures. We also reviewed CQC comment cards which we had sent prior to the inspection for patients to complete about the services provided at the practice.
To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:
These questions therefore formed the framework for the areas we looked at during the inspection.
Updated
4 May 2017
We carried out an announced comprehensive inspection on 30 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
Chu & Tsao Dental Group-Church Road is located in a residential suburb of Liverpool. It comprises a reception and waiting room, two treatment rooms and patient toilet facilities on the ground floor, and a further waiting room and two treatment rooms on the first floor. Parking is available outside the practice. The practice is accessible to patients with disabilities and limited mobility. Access is possible for wheelchair users. The provider has installed a ramp to facilitate access to the practice.
The practice provides general dental treatment to patients on an NHS or privately funded basis. The opening times are Monday to Friday 9.00am to 5.00pm, and Saturday 9.00am to 1.00pm. The practice is staffed by a principal dentist, a practice manager, six associate dentists, a dental therapist, four dental nurses, two receptionists, and two apprentice dental nurses.
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 49 people during the inspection about the services provided. Patients commented that they found the practice excellent, and that staff were friendly, and caring and went out of their way to fit them in in an emergency. They said the dentists listened to them, that they were always given helpful explanations about dental treatment options, and that dental treatments were excellent. Patients commented that the practice was clean and comfortable. Two patients commented it was in need of a re-furbishment. Two patients mentioned they had experienced long delays to appointments.
Our key findings were:
- Staff had received safeguarding training, and knew the processes to follow to raise concerns.
- There were sufficient numbers of suitably qualified and skilled staff to meet the needs of patients.
- Staff had been trained to deal with medical emergencies, and emergency medicines and equipment were available.
- The premises and equipment were clean and secure.
- Guidelines were in place for decontaminating and sterilising instruments.
- Patients’ needs were assessed, and care and treatment were delivered, in accordance with current standards and guidance.
- Patients received information about their care, proposed treatment, costs, benefits, and risks and were involved in making decisions about it.
- Staff were supported to deliver effective care, and opportunities for training and learning were available.
- Patients were treated with kindness, dignity, and respect, and their confidentiality was maintained.
- The appointment system met the needs of patients, and arrangements were in place for patients to be seen in an emergency.
- Services were planned and delivered to meet the needs of patients.
- The practice gathered and took account of the views of patients.
- Staff were supervised, felt involved, and worked together as a team.
- Governance arrangements were in place for the smooth running of the practice.
- The practice had procedures in place to record, analyse and learn from significant events and incidents but not all incidents were recorded.
There were areas where the provider could make improvements and should:
- Review the practice’s system for the recording of significant events.
- Review the practice’s protocols and procedures for promoting the maintenance of good oral health having due regard to guidelines issued by the Department of Health in ‘Delivering better oral health: an evidence-based toolkit for prevention’.
- Review the protocols and procedures to ensure staff are up to date with their mandatory training and their Continuing Professional Development.
- Review staff awareness of Gillick competency and the Mental Capacity Act 2005 and ensure all staff are aware of their responsibilities in relation to their role.
- Review the complaints procedure to ensure details of alternative organisations to which patients can complain are readily available.