26 January 2018
During a routine inspection
We carried out this announced inspection on 26 January 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.
We told the NHS England area team that we were inspecting the practice. We did not receive any information of concern from them.
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
Serenity Dental Spa is in Chorlton and provides NHS and private treatment to adults and children.
A portable ramp is available for people who use wheelchairs and pushchairs. The practice has a small car park, including for blue badge holders. Additional on street parking is available.
The dental team includes three dentists, four dental nurses (one of which is a trainee) who also perform reception and administration duties, a dental hygienist, a dental hygiene therapist and a business manager. 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 28 CQC comment cards filled in by patients and spoke with one other patient. This information gave us a positive view of the practice.
During the inspection we spoke with the principal dentist, three dental nurses and the dental hygiene therapist. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday and Wednesday 9am to 5.30pm
Tuesday 9am to 8pm
Thursday and Friday 9am to 5pm
Saturday by appointment only
Our key findings were:
- The practice was clean and well maintained.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- 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. Evidence of safeguarding training was not available for all members of staff.
- The practice had staff recruitment procedures. We noted that verbal references had not been documented.
- 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 dealt with complaints positively and efficiently.
There were areas where the provider could make improvements and should:
- Review the practice’s safeguarding staff training; ensuring it covers both children and adults and all staff are trained to an appropriate level for their role.
- Review the practice’s infection control and waste segregation procedures and protocols 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.
- Review the practice's recruitment policy and procedures to ensure that DBS checks are carried out accordingly and character references for new staff as well as proof of identification are requested and recorded suitably.
- Review the practice’s sharps procedures giving due regard to the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.