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Inspection report

Date of Inspection: 17 February 2014
Date of Publication: 2 April 2014
Inspection Report published 02 April 2014 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 17 February 2014, talked with people who use the service and talked with staff.

Our judgement

The provider had an effective system to regularly assess and monitor the quality of the service provided.

Reasons for our judgement

We found that the service regularly assessed and monitored the quality of the service provided.

We were told by the registered manager that the practice was part of the Denplan excel accreditation programme which ensured that high standards were set and maintained across all areas within the practice for example during the Denplan excel assessment, records were checked to ensure that” medical histories were updated”, “notes were written up after each consultation” and patients had consented and signed." We were told by the practice manager that patients and their representatives could complete a Denplan questionnaire which, after being completed were placed in a sealed box and taken to Denplan to be analysed. We were told by the registered manager that the results of the questionnaire were discussed at staff meetings to inform staff and ask "what could we do better" so involving staff in improving the quality of the care provided. This showed that the provider was responsive to improving processes and procedures to improve the quality of care delivered.

We saw that there was a policy in place about dealing with accidents. Accidents and incidents were recorded with a description of the event. We observed a notice within the practice that contained information for patients about how to lodge a complaint.The practice manager told us about the complaints policy and how patients would receive an acknowledgement within two working days and a meeting in ten days to discuss the complaint. We were told by the practice manager that if the complainant was not happy with the outcome they were signposted to the Dental Complaints Service. We saw the complaints book and the last entry was in 2004. This meant that the provider had an effective complaints system in place.

We saw records that the practice held a variety of staff meetings along with team practice meetings. We were told by the practice manager that being a small team any issues that arose were dealt with on a daily basis. Staff we spoke with told us that they felt comfortable to discuss all subjects.One member of staff gave examples of how suggestions had been carried through by the registered manager for example the addition of a water dispenser in the waiting area. We were told by the practice manager that the Dentists would organise lunchtime meetings where technology updates, samples and demonstrations of new equipment would take place. We were told by the practice manager that anyone attending interesting courses would give feedback at the practice meeting. This showed that the provider was responsive to continually improving the quality of care because staff were kept up to date and well informed about new techniques.

We looked at the risk assessments for the service and saw that these included, but were not limited to the management of hazardous substances, sharps, daily environment, waste disposal and hand hygiene. We saw that these assessments had been reviewed recently. We saw that the practice carried out monthly legionella checks and yearly a risk assessments were undertaken by an outside company who submitted a report, this last took place in April 2013. This meant that patients were assured that the appropriate assessments had been completed in order to help maintain a safe environment.

We found that management audits were undertaken to support continually improving standards of care. We were told by the practice manager that a recent audit undertaken was to monitor the quality of the x-rays performed where they would be rated as excellent, diagnostically acceptable or unacceptable. This showed that the provider was responsive to improving processes and procedures to improve the quality of care delivered.

We were told by the registered manager that the quality of care delivered by the professional dental team is continually assessed through a peer review process in which the skills available within the team allow treatment options and complex cases to b