Victoria Street Dental Practice Ltd

Updated 27 May 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 9 March 2016 and was led by a CQC inspector who had access to remote advice from a specialist advisor.

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

We also reviewed information we held about the practice. During the inspection we spoke to the dentists and dental nurses. We reviewed policies, procedures and other documents and observed procedures. We reviewed 32 CQC comment cards that we had sent prior to the inspection, for patients to complete about the services provided at the practice.

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 27 May 2016

We carried out an announced comprehensive inspection on 9 March 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

Victoria Street Dental Practice Ltd is located close to the centre of Crewe and comprises a reception and waiting room on the ground floor, a first floor waiting room, four treatment rooms, one of which is situated on the ground floor, a decontamination room, offices, storage and staff rooms. Parking is available on nearby streets. The practice is accessible to patients with disabilities, impaired mobility, wheelchair users and prams via one of the front entrances.

The practice provides general dental treatment to NHS patients of all ages, and general dental treatment on a private basis to patients of all ages.

The practice is open Monday to Friday 9.00am to 5.00pm.

The practice is staffed by six dentists, a practice manager, a clinical dental technician, a dental hygienist, a receptionist, and seven dental nurses, one of whom is a trainee, and another of whom is a dental nurse / receptionist.

One of the principal dentists and the Clinical Manager are the registered managers. 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.

We received feedback from 32 people 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 and hygienic and they found the staff welcoming, friendly, 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 and listened carefully.

Our key findings were:

• The practice recorded and analysed significant events and incidents and received and acted on safety alerts.
• Staff had received safeguarding training and knew the process 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 available.
• Premises and equipment were clean, secure and properly maintained.
• Infection control procedures were in place and the practice followed current guidance.
• Patients’ needs were assessed and care and treatment were delivered in accordance with current legislation, standards and guidance.
• Patients received explanations about their proposed treatment, costs, benefits and risks and were involved in making decisions about it.
• Staff were supported to deliver effective care, and opportunities for training and learning were available.
• Patients were treated with dignity and respect and their confidentiality was maintained.
• The appointment system met the needs of patients.
• Services were planned and delivered to meet the needs of patients and reasonable adjustments were made to enable patients to receive their care and treatment.
• The practice took into account patient feedback but no formal system for obtaining feedback from patients, staff or stakeholders was in place.
• Staff were supervised, felt involved and worked as a team.
• 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 sharps risk assessment having due regard to the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
• Review the practice’s fire risk assessment to ensure it is in accordance with legislation and current guidelines.
• Review the systems in place for obtaining, analysing and acting on feedback from patients, staff and stakeholders about the quality of care provided.