Background to this inspection
Updated
10 March 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.
We inspected Alum Rock Dental Care on 8 December 2015. The inspection team consisted of one CQC inspector and a dental specialist advisor.
Prior to the inspection we reviewed information we held about the provider from various sources. We informed NHS England and Healthwatch that we were inspecting the practice; however we did not receive any information of concern from them. We also requested details from the provider in advance of the inspection. This included their latest statement of purpose describing their values and objectives and a record of patient complaints received in the last 12 months.
During the inspection we toured the premises, spoke with the practice manager, one dentist and three dental nurses/receptionists. One of the practice managers from the providers’ other practices was also available at the practice on the day of the inspection. We spoke with patients and reviewed CQC comment cards which patients had completed. We reviewed a range of practice policies and practice 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
10 March 2016
We carried out an announced comprehensive inspection on 8 December 2015 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
Alum Rock Dental Care provides general dental services to NHS patients. The service is provided by four dentists. They are supported by a practice manager and six dental nurses (two of whom are trainees). The dental nurses are on a rota system and also carry out reception duties. The practice is located in a residential area but close to local amenities. There is wheelchair access to the premises via a portable ramp. There is a waiting area and one treatment room on the ground floor to accommodate patients who cannot use the stairs. The premises consist of a reception area, waiting room, one treatment room, a decontamination room, staff room and accessible toilet facilities on the ground floor. There are a further two treatment rooms, a second waiting room and toilet facilities on the first floor. The office is situated on the second floor. Opening hours are Monday to Friday 10am to 6pm and Saturday 10am to 1pm. 100% of dental care and treatment at this practice is on a NHS basis.
The practice manager 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.
12 patients provided feedback about the practice. We looked at CQC comment cards patients had completed prior to the inspection and we also spoke with patients on the day of our visit. Patients were positive about their experience and they commented that they were treated in a respectful and caring manner. Patients felt that the staff were caring and helpful.
Our key findings were:
- There was appropriate equipment for staff to undertake their duties, and equipment was well maintained. They had access to an automated external defibrillator (AED). An AED is a portable electronic device that analyses life threatening irregularities of the heart including ventricular fibrillation and is able to deliver an electrical shock to attempt to restore a normal heart rhythm.
- The practice had systems to assess and manage risks to patients, including infection prevention and control, health and safety, safeguarding and the management of medical emergencies.
- Staff received training appropriate to their roles.
- Patients told us they found the staff helpful and respectful. Patients commented they felt involved in their treatment and that it was fully explained to them.
- Patients were able to make routine and emergency appointments when needed. However, some patients commented they had to wait beyond their allocated time for emergency appointments.
- The practice had an effective complaints system in place and there was an openness and transparency in how these were dealt with.
- Staff members visited local primary schools to promote good oral health.
There were areas where the provider could make improvements and should:
- Check all audits have learning points documented and resulting improvements can be demonstrated.
- Maintain accurate, complete and detailed records relating to employment of staff. This includes making appropriate notes of verbal references taken and ensuring recruitment checks, including references, are suitably obtained and recorded.
- Review the practice's protocols for completion of dental records giving due regard to guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.