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Comberton Dental Surgery Limited

Inspection Summary


Overall summary & rating

Updated 30 April 2018

We carried out this announced inspection on 11 April 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

Comberton Dental Surgery Limited is in Kidderminster and provides predominantly private treatment with a small NHS provision to patients of all ages.

There is ramped access for people who use wheelchairs and those with pushchairs. The practice has ample car parking available for patients at the rear of the building.

The dental team includes three dentists, seven dental nurses who also work in reception, a decontamination nurse, three dental hygienists, one receptionist, an assistant practice manager and a practice manager. The practice has three treatment rooms.

The practice is owned by a company and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers 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 registered manager at Comberton Dental Surgery Limited was the principal dentist.

On the day of inspection we collected 92 CQC comment cards filled in by patients and spoke with two other patients.

During the inspection we spoke with three dentists, three dental nurses, a decontamination nurse, two receptionists, the assistant practice manager and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday: from 8.30am to 1.30pm and from 2.30pm to 6pm

Tuesday: from 8.30am to 1pm and from 2pm to 6pm

Wednesday: from 8.30am to 1pm and from 2pm to 5pm

Thursday: from 8.30am to 1pm and from 2pm to 5.30pm

Friday: from 8.30am to 1pm

Our key findings were:

  • Effective leadership was provided by the principal dentist and an empowered practice management team.
  • Staff we spoke with felt well supported by the principal dentist and practice management team and were committed to providing a quality service to their patients by ensuring their patients were their main priority.
  • The practice appeared clean and well maintained.
  • The practice had infection control procedures which reflected published guidance.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were mostly available, with the exception of a child reservoir bag which was immediately ordered.
  • The practice had systems to help them manage risk. There was a process in place for the reporting and shared learning when significant events occurred in the practice.
  • The practice staff had embedded safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
  • The practice had thorough staff recruitment procedures.
  • The clinical staff provided patients’ care and treatment in line with current guidelines. New updates were shared with staff at practice meetings.
  • 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. Patients could access routine treatment and urgent and emergency care when required.
  • The practice had effective leadership and culture of continuous improvement.
  • The practice asked staff and patients for feedback about the services they provided. Results of these audits were analysed and action plans implemented.
  • The practice staff dealt with complaints positively and efficiently.
  • The practice staff had suitable information governance arrangements.

There were areas where the provider could make improvements. They should:

  • Review its responsibilities to the needs of people with a disability, including those with hearing difficulties and the requirements of the Equality Act 2010.

Inspection areas

Safe

No action required

Updated 30 April 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. The practice took their responsibilities for patient safety seriously and staff were aware of the importance of identifying, investigating and learning from patient safety incidents.

Staff received training in safeguarding and knew how to recognise the signs of abuse and how to report concerns. The practice had made three safeguarding referrals which they had failed to notify us about; their processes were immediately amended to ensure that notifications would be sent in the future. Safeguarding flow charts with local authority contact details were displayed in reception, the decontamination room and the management office.

Staff were qualified for their roles and the practice completed essential recruitment checks.

The practice held NHS prescriptions which were all logged so that they could be tracked and monitored. Some improvement was required in ensuring the security of these. During our inspection, the practice updated their security processes to rectify this.

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. Appropriate medicines and life-saving equipment were mostly available, with the exception of a child reservoir bag which was immediately ordered.

Effective

No action required

Updated 30 April 2018

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

the relevant regulations.

The dental care provided was evidence based and focused on the needs of the patients. The dentists assessed patients’ needs and provided care and treatment in line with recognised guidance. Patients described the treatment they received as excellent, first class, gentle and professional. 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.

At the time of our inspection the practice were supporting a dental nurse to complete training in sedation.

Staff understood the importance of obtaining informed consent and of working in accordance with relevant legislation when treating patients who might lack capacity to make decisions. We saw examples of positive teamwork within the practice.

Caring

No action required

Updated 30 April 2018

We found that this practice was providing caring services in accordance with

the relevant regulations.

We received feedback about the practice from 94 people. Patients were positive about all aspects of the service the practice provided. They told us staff were caring, polite and always happy to help.

They said that they were given detailed information relating to their treatment, their health conditions were taken into account and said their dentist listened to them. Patients commented that they made them feel at ease, especially when they were anxious about visiting the dentist. Several patients credited the team with helping them overcome previous anxiety when visiting a dentist.

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

Responsive

No action required

Updated 30 April 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.

The practice was aware of the needs of the local population and took those these into account in how it ran. This included providing facilities for disabled patients and families with children.

The practice had access to telephone interpreter services and had some arrangements to help patients with sight or hearing loss. The practice had completed an accessibility audit and highlighted the need for an induction loop; this had not been implemented at the time of our inspection.

The practice took patients views very seriously. They valued compliments from patients and responded to concerns and complaints quickly and constructively. The practice displayed their complaints policy in the reception area and on their website.

Well-led

No action required

Updated 30 April 2018

We found that this practice was providing well-led care in accordance with

the relevant regulations.

Strong and effective leadership was provided by the principal dentist and empowered practice management team. There was a no blame culture in the practice. Staff told us that they felt well supported and could raise any concerns with the principal dentist and practice manager. All the staff we met said that they were happy in their work and the practice was a good place to work.

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, clearly written or typed and 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. The practice carried out regular patient and staff surveys and had a suggestions box in the waiting room.