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Inspection Summary


Overall summary & rating

Updated 31 August 2016

We carried out an announced inspection of this practice on 12 April 2016. Breaches of legal requirements were found. After the inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to safe care and treatment.

We undertook this focused inspection to check they had followed their plan and to confirm they had now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Clock House Dental on our website at www.cqc.org.uk

Our findings were:

Are services Safe?

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

Background

Clock House Dental Practice is situated in Heworth Village area of York, North Yorkshire and is situated over three floors. Three surgeries are located on the ground floor of the practice and a further five are located on the first floor. There are eight dentists (two are the owners/Clinical Directors), a team leader, seven dental nurses (three of which are trainees) four receptionists including a reception supervisor, a lead decontamination nurse and a Dental Hygiene Therapist.

The practice offers a mix of NHS and private dental treatments including preventative advice, routine restorative dental care, private Orthodontic treatments and Dental Implants.

The practice is open:

Monday - Friday 08:30 – 17:00

One of the practice clinical directors 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.

Our key findings were:

  • The practice had implemented Control of Substances Hazardous to Health (COSHH) risk assessments for all dental materials used within the practice.
  • The practice had completed all practice risk assessments including legionella and fire.
  • The practice's recruitment policy and procedures were now suitable and the recruitment arrangements are in line with Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This is to ensure necessary employment checks are in place for all staff and the required specified information in respect of persons employed by the practice is held, in particular all staff now held Disclosure Baring Service checks (DBS).
Inspection areas

Safe

No action required

Updated 31 August 2016

We found that this practice was providing safe care in accordance with

the relevant regulations.

Since the last inspection on 12 April 2016 the practice had effective systems and processes in place to ensure that all care and treatment was carried out safely. For example, the practice had implemented and followed a recruitment policy and procedure for new members of staff joining the team, including the completion of a Disclosure and Barring Service (DBS) check.

All risk assessment had been completed including Legionella and fire safetyand adequate checks were now in place for all dental unit water line management.

Effective

No action required

Updated 25 May 2016

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

Consultations were carried out in line with best practice guidance from the National Institute for Health and Care Excellence (NICE). For example, patients were recalled after an agreed interval for an oral health review, during which their medical histories and examinations were updated and recorded also any changes in risk factors were also discussed and recorded.

The practice followed best practice guidelines when delivering dental care. These included guidance from the Faculty of General Dental Practice (FGDP) and NICE. The practice focused on prevention although the dentists were not aware of the ‘Delivering Better Oral Health’ toolkit (DBOH) with regards to fluoride application and oral hygiene advice.

Patients dental care records provided information about their current dental needs and past treatment. The dental care records we looked at included discussions about treatment options, relevant X-rays including grading and justification. The practice monitored any changes to the patients oral health and made referrals for specialist treatment or investigations where indicated in a timely manner.

Staff were registered with the General Dental Council (GDC) and maintained their registration by completing the required number of hours of continuing professional development (CPD). Staff were supported to meet the requirements of their professional registration.

Caring

No action required

Updated 25 May 2016

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

Staff explained that enough time was allocated in order to ensure the treatment and care was fully explained to patients in a way which patients understood.

Comments we received from the 21 CQC comment cards providing feedback were positive about the care and treatment they received in the practice. They told us they were involved in all aspects of their care and were very pleased with the service. They found the staff helpful, gentle, patient and friendly. Also the staff had good communication skills, were efficient and they treated patients with dignity and respect in a clean and tidy environment.

We observed patients being treated with respect and dignity during interactions at the reception desk and over the telephone.

Responsive

No action required

Updated 25 May 2016

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

Patients could access routine treatment and urgent care when required. The practice offered daily access for patients experiencing dental pain which enabled them to receive treatment quickly.

The practice had a ramp for patients requiring disability access and where possible reasonable adjustments had been made to accommodate patients with a disability or limited mobility.

The downstairs surgeries were available for patients who required one and all dentists could use one surgery as required accommodating their own patients.

The practice had a complaints process for patients who wished to make a complaint; however this was not accessible within the practice or within the various waiting areas. Staff recorded complaints and cascaded learning to staff. They also had patient advice leaflets available in the waiting room.

Well-led

No action required

Updated 25 May 2016

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

There was a clearly defined management structure in place. The registered manager and team leader was responsible for the day to day running of the practice although they were not on site daily there was always someone available to talk to.

Staff reported the registered manager was approachable; they felt supported in their roles and were freely able to raise any issues or concerns with them at any time. The culture within the practice was seen by staff as open and transparent.

The practice did not have regular staff meetings due to turn over of staff. We did see evidence of a staff meeting, peer review meeting and a nurses meeting although this process seemed to be new and the registered manager was working towards monthly meetings.

The practice undertook various audits to monitor their performance and help improve the services offered. The audits included infection prevention and control and X-rays. The X-ray audit findings were within the guidelines of the National Radiological Protection Board (NRPB).

They conducted patient satisfaction surveys and they were currently undertaking the NHS Friends and Family Test (FFT).