You are here

Inspection Summary


Overall summary & rating

Updated 8 April 2016

We carried out an announced comprehensive inspection on 16 February 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

MAC Dental Centre Ltd is located close to the centre of Macclesfield and comprises a reception and waiting room on the ground floor and a first floor waiting room, five treatment rooms, two of which are situated on the ground floor, a decontamination room, offices, storage and staff rooms. Parking is available to the rear of the practice. The practice is accessible for patients with disabilities at the front and rear entrances.

The practice provides general dental treatment to NHS patients of all ages, and general dental treatment and a range of more complex treatments, for example, dental implants, on a private basis.

The practice is open Monday to Thursday 8.30am to 6.00pm and Friday 8.30am to 5.00pm.

The practice is staffed by five dentists, a business manager, a practice manager, five dental nurses, one of whom is the senior nurse and another three of whom are trainees, a dental therapist and four receptionists.

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.

Forty people provided feedback on CQC comment cards about the services provided. Every comment was very positive about the staff and the service. Patients commented that the practice was clean, hygienic and modern, and they found the staff friendly, considerate and caring. They had trust in the staff and confidence in the dental treatments, and said that they were always given clear, detailed and understandable explanations about dental treatment. Several patients commented that the dentists put patients at ease, have their patients best interests at heart and listen carefully.

Our key findings were:

  • The practice recorded and analysed significant events, incidents and complaints and cascaded learning to staff.
  • Staff had received safeguarding training and knew the processes to follow to raise any concerns.
  • There were sufficient numbers of suitably qualified staff to meet the needs of patients.
  • Staff had been trained to deal with medical emergencies and emergency medicines and equipment were readily available.
  • Premises and equipment were clean, secure and properly maintained.
  • Infection control procedures were in place and the practice followed published guidance.
  • Staff were supported to deliver effective care, and opportunities for training and learning were available.
  • Clinical staff were up to date with their continuing professional development and met the requirements of their professional registration.
  • Patient’s care and treatment was planned and delivered in line with evidence-based guidelines, and current practice and legislation.
  • Patients received clear explanations about their proposed treatment, costs, benefits and risks and were involved in making decisions about it.
  • Patients were treated with dignity and respect and confidentiality was maintained.
  • The appointment system met the needs of patients and delays were kept to a minimum.
  • The practice staff felt involved and worked as a team.
  • The practice sought feedback from staff and patients about the services they provided.
  • Governance arrangements were in place for the smooth running of the practice and the practice had a structured plan in place to audit quality and safety.

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

  • Review the practice’s infection control procedures and protocols having due regard to 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, specifically in relation to cleaning equipment.
  • Review the practice’s sharps procedures having due regard to the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
  • Review the current legionella risk assessment and implement the required actions 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 the practice’s responsibilities in relation to the Control of Substances Hazardous to Health 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.
Inspection areas

Safe

No action required

Updated 8 April 2016

We found that this practice was providing safe care in accordance with the relevant regulations.

There were systems in place for identifying, investigating and learning from incidents relating to patient safety.

Staff understood their responsibilities for identifying and reporting potential abuse. Staff were trained in safeguarding and there were policies and procedures in place for staff to follow.

The practice had a recruitment policy and recruitment procedures in place which were in accordance with current regulations.

Risks had been identified and assessed and staff were aware of how to minimise risks.

We found the equipment used in the practice, including medical emergency and radiography equipment, was well maintained and tested at regular intervals.

There were arrangements in place for managing medicines, including emergency medicines, to ensure they were stored safely.

There were systems in place to reduce and minimise the risk and spread of infection and the premises and equipment were clean, secure and properly maintained.

Effective

No action required

Updated 8 April 2016

We found that this practice was providing effective care in accordance with the relevant regulations.

The practice provided evidence-based care in accordance with relevant published guidance. The practice monitored patients’ oral health and gave appropriate health promotion advice tailored to the patient’s individual needs. Dentists explained treatment options and costs to patients to assist them in making an informed decision. Consent was obtained before treatment was commenced.

The dentists referred patients to other services for care in a timely manner.

Staff were registered with the General Dental Council and engaged in continuing professional development, (CPD), to meet the requirements of their registration. Staff were supported through training, appraisals, and opportunities for development.

Caring

No action required

Updated 8 April 2016

We found that this practice was providing caring services in accordance with the relevant regulations.

Patients commented that the staff were caring, polite, and friendly. They told us that they were treated with dignity and respect and their privacy was maintained. Patient information was handled confidentially.

We saw that treatment was clearly explained and patients were provided with written treatment plans.

Patients with urgent dental needs or in pain were responded to promptly and were usually seen by a dentist on the same day.

Responsive

No action required

Updated 8 April 2016

We found that this practice was providing responsive care in accordance with the relevant regulations.

Patients had access to appointments and choice of dentists, to suit their preferences, and emergency appointments were available on the same day.

The practice had considered the needs of different groups of people and had made the practice easily accessible to people with disabilities, impaired mobility, and to wheelchair users.

Access to interpretation services was available and a number of the practice staff spoke second languages.

The practice used the skill mix, experience and knowledge of the staff to improve outcomes for their patients.

Information about emergency treatment and out of hours care was displayed at the practice entrance, on the answerphone and contained in the practice leaflet.

The practice had a complaints policy which was displayed in the waiting room and on the practice website.

Well-led

No action required

Updated 8 April 2016

We found that this practice was providing well-led care in accordance with the relevant regulations.

The practice had a clear leadership structure in place and shared roles and responsibilities amongst staff. The practice had robust governance arrangements in place and clear policies and procedures which were being followed by staff.

Staff were supported to maintain their professional development and skills. The practice staff met regularly to review all aspects of the delivery of dental care and the management of the practice.

Auditing processes and learning from complaints were used to monitor and improve performance.

Patients and staff were able to feedback compliments and concerns regarding the service and the practice acted on them. Patients commented that the practice took notice of their concerns.