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Inspection Summary


Overall summary & rating

Updated 6 September 2018

We carried out this announced inspection on 10 August 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a CQC inspector who was supported by a specialist dental adviser.

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 form the framework for the areas we look at during the inspection.

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

Birdgate Dental Practice is in the centre of Pickering and provides private dental treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking and public transport facilities are available near the practice.

The dental team includes two dentists, a treatment coordinator and oral health educator, three dental nurses, one dental hygiene therapist, practice manager and a receptionist. The practice has three treatment rooms.

The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.

On the day of inspection we collected 50 CQC comment cards filled in by patients.

During the inspection we spoke with one dentist, two dental nurses, the treatment coordinator and the practice manager. We looked at the practice’s policies and procedures and other records about how the service is managed.

The practice is open: Monday to Friday 9am-5pm

Our key findings were:

  • The practice appeared clean and well maintained.
  • The practice staff had infection control procedures which reflected published guidance.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
  • The practice had systems to help them manage risk. Not all the legionella recommendations had been carried out and fire safety systems needed review.
  • The practice staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
  • The clinical staff provided patients’ care and treatment in line with current guidelines.
  • Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • The practice was providing preventive care and supporting patients to ensure better oral health.
  • The appointment system met patients’ needs.
  • The practice had effective leadership and a culture of continuous improvement.
  • Staff felt involved and supported and worked well as a team.
  • The practice asked staff and patients for feedback about the services they provided.
  • The practice staff dealt with complaints positively and efficiently.
  • The practice staff had suitable information governance arrangements.

There were areas where the provider should make improvements.

  • Review the practice's Legionella risk assessment and implement monthly water temperature testing the outlets.
  • Review the practice's systems for checking and monitoring equipment taking into account relevant guidance and ensure that all equipment is well maintained in particular the confirmation of the safety of electrical fixed wiring and gas safety in the practice.
  • Review the fire safety risk assessment and review the installation of emergency lighting. Ensure that any fire testing of the system is undertaken regularly and fire drills are in place.
  • Review the storage of medicines requiring refrigeration to ensure they are stored in line with the manufacturer’s guidance and the fridge temperature is monitored and recorded.

Inspection areas

Safe

No action required

Updated 6 September 2018

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

The practice had systems and processes to provide safe care and treatment. They used learning from incidents and complaints to help them improve.

Staff received training in safeguarding and knew how to recognise the signs of abuse and how to report concerns.

Staff were qualified for their roles.

Premises and equipment were clean and properly maintained. The practice followed national guidance for cleaning, sterilising and storing dental instruments.

The practice had suitable arrangements for dealing with medical and other emergencies. Medicines were stored in the fridge, we noted fridge temperatures were not monitored and recorded.

The practice had systems in place to manage risks. Improvements were needed to manage the risks associated with fire, electrical, gas and legionella safety checks.

Effective

No action required

Updated 6 September 2018

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

the relevant regulations.

The dentists assessed patients’ needs and provided care and treatment in line with recognised guidance. Patients described the treatment they received as excellent, professional and caring. The dentists discussed treatment with patients so they could give informed consent and recorded this in their records.

The practice had clear arrangements when patients needed to be referred to other dental or health care professionals.

The practice supported staff to complete training relevant to their roles and had systems to help them monitor this.

Caring

No action required

Updated 6 September 2018

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

We received feedback about the practice from 50 people. Patients were positive about all aspects of the service the practice provided. They told us staff were friendly, reassuring and polite. They said that they were given reassurance if they were nervous and were given helpful and clear explanations about dental treatment.

We saw that staff protected patients’ privacy and were aware of the importance of confidentiality. Patients said staff treated them with dignity and respect.

Responsive

No action required

Updated 6 September 2018

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

The practice’s appointment system was efficient and met patients’ needs. Patients could get an appointment quickly if in pain.

Staff considered patients’ different needs. This included providing facilities for disabled patients and families with children. The practice had access to interpreter services if required and had arrangements to help patients with sight impairment.

The practice took patients views seriously. They valued compliments from patients and responded to concerns and complaints quickly and constructively.

Well-led

No action required

Updated 6 September 2018

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

On the day of the inspection, all staff were welcoming and open to discussion and feedback.

The practice had arrangements to ensure the smooth running of the service. These included systems for the practice team to discuss the quality and safety of the care and treatment provided. There was a clearly defined management structure and staff felt supported and appreciated.

The practice team kept complete patient dental care records which were stored securely.

The practice monitored clinical and non-clinical areas of their work to help them improve and learn. This included asking for and listening to the views of patients and staff.