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Inspection Summary


Overall summary & rating

Updated 17 December 2015

We carried out an announced comprehensive inspection on 20 September 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

This report is about the service provided at Evesham Place Dental Practice by Evesham Place Ltd which is owned by Andrew Browne, a dentist and the clinical director. The practice provides mainly private dental treatment but also some NHS treatment. Andrew Browne also provides NHS out of hours emergency dental treatment for all of South Warwickshire at the practice under a separate CQC registration. We have produced a separate report about this although many elements of the two services are the same.

Evesham Place has four dentists (including the clinical director), a regular locum dentist, three dental hygienists and eight dental nurses. The clinical team are supported by two full time practice managers, a senior receptionist and three receptionists. The clinical director 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.

The practice has five dental treatment rooms and a decontamination room for the cleaning, sterilising and packing of dental instruments. The reception area and main waiting room are on the ground floor and there is another smaller waiting room on the first floor.

Before the inspection we sent Care Quality Commission comment cards to the practice for patients to use to tell us about their experience of the practice. We collected 40 completed cards. Patients spoke highly of the practice team and were positive about their experience of being a patient there. People described receiving excellent advice, care and treatment and described various members of the team as friendly, approachable, cheerful and caring. Several patients specifically mentioned how clearly their dentist explained their treatment to them and what their options were for this. The practice showed us the results of their 2015 NHS Friends and Family Test monthly surveys for July to September 2015. These showed that from 71 responses 48 patients were ‘extremely likely’ to recommend the practice and 21 were ‘likely’ to do so. Of the remainder one was neutral about this. Only one said they were ‘unlikely’ to recommend the practice. The practice carried out its own survey in August 2015 and 91.3% of the responses received were positive.

Our key findings were:

  • Patients who completed Care Quality Commission comment cards were pleased with the care and treatment they received and complimentary about the whole practice team.

  • The practice had an established process for reporting and recording significant events and accidents to ensure they investigated these and took remedial action. The practice used significant events to make improvements and shared learning from these with the team.
  • The practice was visibly clean and a number of patients commented on their satisfaction with hygiene and cleanliness.

  • The practice had well organised systems to assess and manage infection prevention and control.

  • The practice had suitable safeguarding processes and staff understood their responsibilities for safeguarding adults and children.

  • The practice had recruitment policies and procedures and used these to help them check the staff they employed were suitable. The written policy did not fully reflect the requirements of legislation although the practice obtained the correct information.

  • Dental care records provided information about patients’ care and treatment. Some were more comprehensive than others.

  • Staff received training appropriate to their roles and were supported in their continued professional development (CPD).

  • Patients were able to make routine and emergency appointments when needed.

  • The practice had systems including audits to assess, monitor and improve the quality and safety of the services provided.

  • The practice had systems to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients, staff and visitors.

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

  • Establish a written policy regarding significant event reporting and recording to support their current practice.
  • Update the practice policy for safe use of sharps to include reference to the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 and the EU Directive on the safer use of sharps which came into force in 2013
  • Keep a record of the allocation of prescription pads in accordance with national guidance from NHS Protect.
  • Review their recruitment policy to fully reflect the requirements of Regulation 19(3) and Schedule 3 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014.
  • Record the reasons for taking X-rays and the grading of these every time one is taken.
  • Develop a structured process for recording staff induction to confirm individual staff knowledge and competence in the areas covered.
Inspection areas

Safe

No action required

Updated 17 December 2015

We found that this practice was providing safe care in accordance with the relevant regulations. The practice had systems for infection prevention and control, clinical waste control, management of medical emergencies, maintenance and testing of equipment, dental radiography (X-rays) and child and adult safeguarding. Some policies needed to be reviewed and updated to reflect current legislation and guidance although actual practices were safe.

Effective

No action required

Updated 17 December 2015

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

The dental care provided focussed on the needs of the patients. The dental care records we looked at provided information about patients’ care and treatment. We noted that comprehensive treatment plans were one of the practice’s strengths. Clinical staff were registered with the General Dental Council and completed continuing professional development to meet the requirements of their professional registration. Staff understood the importance of obtaining informed consent and of working in accordance with relevant legislation when treating patients who may lack capacity to make decisions. We identified that the dentists did not all consistently record the reasons they had taken X-rays and that some clinical notes were more detailed than others.

Caring

No action required

Updated 17 December 2015

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

We gathered patients’ views from 40 completed Care Quality Commission comment cards. We did not have the opportunity to speak with patients at the practice. People described receiving excellent advice, care and treatment and described various members of the team as friendly, approachable, cheerful and caring. Patients confirmed the dentists explained their treatment options and gave them confidence. During the day we saw reception staff and dental nurses dealing with patients in a welcoming way and heard reception staff being helpful and caring on the telephone. Recent results from the NHS Friends and Family test and an in house survey shared by the practice were also positive.

Responsive

No action required

Updated 17 December 2015

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

Many patients who completed CQC comment cards told us they had been patients at the practice for a long time. Several had taken time to write in detail about ways the practice team had responded to their needs. The practice ensured that patients unable to use stairs had their appointments in a ground floor surgery. Patients could access treatment and urgent and emergency care when required.

Information was available for patients at the practice and on the practice website. The practice had a complaints procedure which was available for patients and we saw evidence that they responded to complaints in a positive and constructive way and used these to help them improve.

Well-led

No action required

Updated 17 December 2015

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

The practice had arrangements for managing and monitoring the quality of the service. The two practice managers demonstrated good teamwork and effective sharing of responsibilities for the day to day running of the practice. All the staff we spoke with were aware of the organisational structure and leadership arrangements.

The practice had policies, systems and processes which were available to all staff. We highlighted that a small number of policies needed to be reviewed to make sure they were up to date and contained current information.

There was a friendly and supportive culture at the practice and the team were committed to learning, development and improvement. The staff team were positive, professional and enthusiastic and felt valued by the provider.