Archived: Cloves Dental Practice

Updated 11 February 2016

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 practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The inspection took place on 11 January 2016 and was conducted by a CQC inspector and a specialist dental advisor.

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.

Prior to the inspection we asked the practice to send us some information which we reviewed. This included the complaints they had received in the last 12 months, their latest statement of purpose, the details of their staff members, their qualifications, and proof of registration with their professional bodies.

We also reviewed the information we held about the practice and found there were no areas of concern.

During the inspection we spoke with the principal dentist and one associate dentist, practice manager and two dental nurses. We reviewed policies, procedures and other documents. We received feedback from 41 patients during the inspection process.

Updated 11 February 2016

We carried out an announced comprehensive inspection on 11 January 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 providing well-led care in accordance with the relevant regulations.

Background

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. In addition to the principal, the practice engaged two associate dentists, a hygienist, and employed three trained dental nurses, with one nurse having lead responsibility for managing reception. The practice manager is also a trained dental nurse. All the dental nurses work as a team and are responsible for the cleaning of the practice.

The practice is located at ground level within a range of shops and is accessible to wheelchair users. Due to building constraints the toilets are not accessible for patients with limited mobility but disabled toilet facilities are located nearby.

The practice had two treatment rooms, a staff kitchen area, reception and waiting room and one decontamination room for cleaning, sterilising, and packing dental instruments. The practice is open Monday to Thursday 9.00 am to 5.00 pm, Fridays 9.00 am to 1.00 pm. For private patients, the practice has extended opening hours available.

We spoke with four patients during our inspection and received 41 comments cards that had been completed by patients prior to our inspection. We received positive comments about the cleanliness of the premises, the empathy and responsiveness of staff, and the quality of treatment provided.

Four patients told us that staff explained treatment plans to them well. Patients reported that the practice had seen them on the same day for emergency treatment. Patients commented that the service they received was good, and that they were always clear about the costs involved in their treatment.

Our key findings were:

• Staff had received safeguarding training and knew the processes to follow to raise any concerns.
• Staff had been trained to deal with medical emergencies and appropriate medicines and life-saving equipment were readily available and accessible.
• Infection control procedures were in place and staff had access to personal protective equipment.
• Patients’ care and treatment was planned and delivered in line with evidence based guidelines and current legislation.
• Patients received clear explanations about their proposed treatment, costs, benefits, and risks and were involved in making decisions about them.
• 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.
• We found that systems, and risk assessments, were in place to give oversight and ensure compliance with regulations, and safety however we found that the management of some medicines was not adequately robust to keep patients safe.
• We found that regular audits of X-rays were not in place to manage performance, identify risks, mitigate, and drive improvements.

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

• Ensure safe storage and robust stock management of medicines that could be dispensed to patients.
• Ensure audits relating to X-rays are undertaken at regular intervals to help improve the quality of service.
• Record peer review discussions for future and reflective learning.