Updated 3 December 2019
We carried out this announced inspection on 21st October 2019 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
Titley, Darby & Associates is located in Penn Fields, Wolverhampton and provides NHS and private treatment to adults and children.
There is level access for people who use wheelchairs and those with pushchairs. There is a private car park within the grounds of the surgery. There is also parking available in a nearby residential estate.
The dental team includes eight dentists, ten dental nurses, three dental hygienists, one locum dental nurse who held a long term contract, two receptionists and one practice manager. The practice has six treatment rooms.
The practice is owned by a partnership 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 Titley, Darby & Associates is the senior partner.
We sent 50 comment cards in advance of our visit to the practice for patients to complete. On the day of inspection, we collected 34 CQC comment cards filled in by patients which equated to a 64% response rate. On the day of inspection, we spoke with two other patients.
During the inspection we spoke with three dentists including the senior partner, three 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 to Thursday 8.45am to 5.30pm, and Friday 8.45am to 4.30pm
Our key findings were:
- The practice appeared clean and well maintained.
- The provider had infection control procedures which reflected published guidance.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- The provider had systems to help them manage risk to patients and staff.
- The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The provider had thorough staff recruitment procedures.
- 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.
- Staff provided preventive care and support to patients to ensure better oral health.
- The appointment system took account of patients’ needs.
- The provider had effective leadership and culture of continuous improvement.
- Staff felt involved and supported and worked well as a team.
- The provider asked staff and patients for feedback about the services they provided.
- The provider had suitable information governance arrangements.
There were areas where the provider could make improvements. They should:
- Take action to ensure that all the staff have received training, to an appropriate level, in the safeguarding of children and vulnerable adults. .
- Take action to ensure that all clinical staff have adequate immunity for vaccine preventable infectious diseases.
- Review practice protocols regarding the prescribing of antibiotic medicines taking into account the guidance provided by the Faculty of General Dental Practice.