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Inspection report

Date of Inspection: 23 November 2012
Date of Publication: 12 December 2012
Inspection Report published 12 December 2012 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 23 November 2012, observed how people were being cared for and talked with people who use the service. We talked with staff.

Our judgement

The provider had an effective system to regularly assess and monitor the quality of service that people receive. The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

Reasons for our judgement

We saw the provider had carried out a patient survey of 50 people who used the service in November 2012. They received a 100% rate from the survey and the feedback was excellent or very good. The results of the survey had been analysed and an action plan put in place, which was due to be discussed at a future team meeting. This shows that the provider had gathered information from people who use the service and were making necessary changes to improve the service.

We saw that the provider carried out audits of their service in a number of areas. The audits covered patient records, reception forms, infection control as well as technical audits relating to equipment. Different members of staff had responsibility for auditing specific areas. The audits had all been carried out between April 2012 and November 2012 and there was a schedule in place for when the audits would be repeated in 2013. All of the audits had an analysis attached and action plans so that the service could be improved. this shows that the provider continually reviews their practices.

We saw that the provider records adverse events, incident and near misses. The most recent record was in July 2010 and there had been no incidents since.

We saw that the provider had a complaints procedure in place. The procedure included both internal methods of dealing with complaints and external agencies that people using the service could complain to. There had been no complaints received about the provider. This information was also displayed in the reception area.

We saw that the provider had a disciplinary policy for staff and clear guidance about investigations into any misconduct by a person employed. There had been no investigations by the provider as none of the staff had misconducted themselves.

The provider had environmental risk assessments in place which showed that they monitored and managed risks to people who used, worked in or visited the service.

We saw a maintenance plan with renewal dates for testing various areas such as fire extinguishers and fire risk assessments and portable appliance testing. This showed that the provider was identifying and managing potential

risks within the dental surgery.