Updated 17 January 2018
We carried out this announced inspection on 30 November 2017 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.
We told the NHS England area team that we were inspecting the practice. They did not provide any information for us to take into account.
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
Abbotsford House Dental Practice is in Birmingham and provides NHS and private treatment to patients of all ages.
There is level access for people who use wheelchairs and pushchairs. Public car parking facilities are available near the practice. There are no dedicated spaces for patients who are blue badge holders; however, patients are able to park directly outside the practice, if they require this.
The dental team includes one dentist, three dental nurses, one dental hygienist therapist, one hygienist and a practice manager. The dental nurses and practice manager also carry out reception duties. The practice has two 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 52 CQC comment cards filled in by patients. This information gave us a positive view of the practice.
During the inspection we spoke with one dentist, two dental nurses 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 10am – 7pm
Tuesday 8:30am – 5:30pm
Wednesday 8:30am – 5:30pm
Thursday 8:30am – 5:30pm
Friday 8:30am – 4:30pm
Our key findings were:
- The practice was clean and well maintained.
- The practice had infection control procedures which reflected published guidance. We identified some necessary improvements and the practice responded promptly to resolve these.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available. We identified some necessary improvements and the practice responded promptly to address these.
- The practice had systems to help them manage risk.
- The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
- The practice had staff recruitment procedures but these processes required improvements.
- 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 appointment system met patients’ needs.
- The practice had effective leadership. 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 had not received any written complaints within the past few years. They had procedures to deal with these if they were received.
There were areas where the provider could make improvements. They should:
- Review the current Legionella risk assessment and implement the required actions including the monitoring and recording of water quality.
- Review availability of medicines and equipment to manage medical emergencies taking into account guidelines issued by the British National Formulary, the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.
- 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 the practice's current audit protocols to ensure audit learning points are documented and shared with all relevant staff.
- Review the decontamination room and make arrangements for the installation of a sink for hand washing.