Updated 20 October 2017
We carried out this announced inspection on 21 September 2017 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 second CQC inspector.
We told the NHS England Cheshire and Merseyside area team that we were inspecting the practice. We did not receive any information of concern from them.
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
The Kirby Family Dental Centre is in the centre of Kirby and provides dental care and treatment to adults and children on an NHS and privately funded basis.
There is level access to the practice. The practice has four treatment rooms. Car parking is available near the practice.
The dental team includes two principal dentists, four associate dentists and eight dental nurses, three of whom are trainees. The dental nurses also carry out reception duties. The team is supported by a practice manager.
The practice is owned by an individual who is one of the principal dentists there. They 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 six people during the inspection about the services provided. The feedback provided was positive about the practice.
During the inspection we spoke to two dentists, dental nurses and the practice manager. We looked at practice policies, procedures and other records about how the service is managed.
The practice is open:
Monday to Thursday 8.30am to 5.30pm
Friday 8.30am to 2.00pm.
Our key findings were:
- The practice was clean and well maintained.
- The practice had infection control procedures in place which reflected published guidance.
- The practice had safeguarding processes in place and staff knew their responsibilities for safeguarding adults and children.
- The practice had staff recruitment procedures in place.
- Staff provided patients’ care and treatment in line with current guidelines.
- The practice had a procedure in place for dealing with complaints.
- Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
- The appointment system took patients’ needs into account. Dedicated emergency appointments were available.
- The practice had a leadership structure. Staff felt involved and supported and worked well as a team.
- The practice asked patients and staff for feedback about the services they provided.
- Staff knew how to deal with emergencies. All the recommended medical emergency medicines and most of the recommended medical emergency equipment was available, except medical oxygen masks with a reservoir.
- The practice had systems in place to help them manage risk but not all risks had not been assessed and mitigated.
There were areas where the provider could make improvements and should:
- Review the practice’s arrangements for receiving and responding to patient safety alerts, recalls and rapid response reports issued from the Medicines and Healthcare products Regulatory Agency and through the Central Alerting System, as well as from other relevant bodies such as Public Health England.
- Review the practice’s system for assessing, monitoring and mitigating the various risks arising from the undertaking of the regulated activities, specifically in relation to staff immunity to infection following vaccination, and in relation to the secure storage of infectious waste externally.
- Establish whether the practice is in compliance with its legal obligations under the Ionising Radiations Regulations 1999 and the Ionising Radiation (Medical Exposure) Regulations 2000.
- Review the practice’s systems for ensuring staff are up to date with their recommended training and their continuing professional development.