Archived: Stephen Emmett's Dental Surgery

Updated 9 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 was led by a CQC inspector who was supported by a second inspector. They had remote access to a specialist dental advisor.

We informed the local NHS England area team that we were inspecting the practice. We did not receive any information of concern from them.

We spoke with two dentists, two dental nurses, the practice supervisor and the area manager. To assess the quality of care provided we looked at practice policies and protocols and other records relating to the management of the service.

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 therefore formed the framework for the areas we looked at during the inspection.

Updated 9 May 2017

We carried out an announced comprehensive inspection on 31 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

Stephen Emmett's Dental Surgery is a dental practice providing NHS and private treatment for both adults and children. The practice is based in a converted terraced property in Gorton, Manchester.

The practice has two dental treatment rooms which are located on the ground floor and the first floor, a decontamination room, reception area and a staff kitchen/X-ray room.

There are four dentists, four dental nurses (one of whom is a trainee), a decontamination staff member, a receptionist and a practice supervisor.

The practice’s opening hours are 8.45am to 12.15pm and 1.30pm to 7pm on Mondays, 8.45am to 12.15pm and 1.30pm to 5.30pm Tuesday and Thursday, 8.45am to 12.15pm and 1.30pm to 5pm Wednesday and 8.45am to 3.15pm Fridays.

One of the practice partners is the registered manager. A registered manager is a person who is registered with the Care Quality Commission (CQC) 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.

During the inspection we received feedback from 14 patients. The patients were positive about the care and treatment they received at the practice.

Our key findings were:

• The practice was well organised, visibly clean and free from clutter.
• An Infection prevention and control policy was in place. We saw the sterilisation procedures followed recommended guidance.
• The practice had systems for recording incidents and accidents.
• The practice had a safeguarding policy and staff were aware on how to escalate safeguarding issues for children and adults should the need arise.
• Staff received annual medical emergency training. Equipment for dealing with medical emergencies reflected guidance from the resuscitation council but minor adjustments were necessary.
• Dental professionals provided treatment in accordance with current professional guidelines.
• Patient feedback was regularly sought and reflected upon.
• Patients could access urgent care when required.
• Dental professionals were maintaining their continued professional development (CPD) in accordance with their professional registration.
• There were systems to deal with complaints in an efficient and positive manner.

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 (MHRA) and through the Central Alerting System (CAS), as well as from other relevant bodies such as, Public Health England (PHE).
• Review the security of prescription pads in the practice and ensure there are systems in place to monitor and track their use.
• Review the practice’s safeguarding staff training; ensuring it covers both children and adults and all staff are trained to an appropriate level for their role and aware of their responsibilities.
• Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.
• Review the current Legionella risk assessment and implement the required actions including the monitoring and recording of water temperatures, giving due regard to the 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.
• Review its responsibilities as regards to the Control of Substance Hazardous to Health (COSHH) Regulations 2002 and, ensure all documentation is up to date and staff understand how to minimise risks associated with the use of and handling of these substances.
• Review the health and safety systems to carry out risk assessments and document the actions taken by the practice to reduce risks.
• Review the practice’s sharps procedures giving due regard to the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
• Review the storage of dental care records to ensure they are stored securely.
• Review the practice’s audit protocols of various aspects of the service, such as radiography and dental care records at regular intervals to help improve the quality of service. The practice should also check all audits have documented learning points and the resulting improvements can be demonstrated.