We carried out an announced comprehensive inspection on 17 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 not 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 not providing well-led care in accordance with the relevant regulations.
Background
Bowes Road Dental Practice provides NHS and private dental treatment to patients of all ages. The services provided include preventative advice and treatment and routine restorative dental care.
The practice staffing consists of a principal dentist, two associate dentists, three dental nurses, one hygienist and a receptionist/practice manager.
The principal dentist is registered with the Care Quality Commission (CQC) as an individual. 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 consists of three treatment rooms, a waiting area for patients and reception area, a staff room and an office.
The practice opening hours are Monday to Friday 8.30am to 5.30pm and every other Saturday 8.30am to 12.30pm
36 patients provided feedback about the service. Patients we spoke with and those who completed comment cards were very positive about the care they received and about the service. Patients told us that they were happy with the dental treatment and advice they had received.
Our key findings were:
- There were systems in place to ensure that equipment including the suction apparatus, compressor unit, autoclave and fire extinguishers had been serviced regularly.
- Patients’ care and treatment was planned and delivered in line with current legislation and evidence based guidelines such as from the National Institute for Health and Care Excellence (NICE).
- Patients were treated with dignity and respect and patient confidentiality was maintained.
- The practice had a procedure for handling and responding to complaints.
- The appointment system met the needs of patients and waiting times were kept to a minimum.
- The practice had not ensured that all the specified information relating to persons employed at the practice was appropriately maintained and recorded.
- Not all staff members had undertaken training in key areas such as safeguarding children and adults and infection control; there was lack of oversight of staff’s continuing professional development (CPD) activity and it was not being suitably monitored.
- Infection control protocols were not being followed in line with recommended national guidance.
- The practice had carried out limited risk assessments to ensure the health and safety of staff and patients.
- Governance systems were not effective. There were a range of policies and procedures in place; however staff had little understanding of the policies with little adaptation to the practice.
We identified regulations that were not being met and the provider must:
- Ensure the practice’s infection control procedures and protocols were suitable giving 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’.
- Ensure systems are in place to assess, monitor and improve the quality of the service.
- Ensure the practice has effective systems in place to be assured of staff’s continuing professional development and to have a system for appraising staff performance.
- Ensure an effective system is established to assess, monitor and mitigate the various risks arising from undertaking of the regulated activities.
- Ensure audits of various aspects of the service, such as radiography and dental care records are undertaken at regular intervals to help improve the quality of service. The practice should also ensure that where appropriate audits have documented learning points and the resulting improvements can be demonstrated.
You can see full details of the regulations not being met at the end of this report.
There were areas where the provider could make improvements and should:
- Review the practice’s arrangements for receiving and responding to patient safety alerts, recalls and rapid response reports issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and through the Central Alerting System (CAS), as well as from other relevant bodies, such as Public Health England (PHE).
- Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.
- Review the practice's policy and the storage of products identified under Control of Substances Hazardous to Health (COSHH) 2002 Regulations to ensure a risk assessment is undertaken and the products are stored securely.