Archived: Freetown Way Dental Practice

Updated 17 December 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The inspection was carried out on 3rd November 2015 and was led by a CQC inspector and a specialist advisor was present.

We informed NHS England area team and Healthwatch that we were inspecting the practice; however we did not receive any information of concern from them.

The methods that were used to collect information at the inspection included interviewing staff, observations and reviewing documents.

During the inspection we spoke with three dentists, two dental nurses and the practice manager. We saw policies, procedures and other records relating to the management of the service. We reviewed 25 CQC comment cards that had been completed.

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 therefore formed the framework for the areas we looked at during the inspection.

Updated 17 December 2015

We carried out an announced comprehensive inspection on 3 November 2015 to ask the practice the following key questions; Are services safe, effective, caring, responsive and well-led?

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

Freetown Way Dental Practice is situated in Hull, Humberside. The practice offers NHS treatments including prevention advice and routine restorative dental care, it also provides walk-in services for patients who are in pain and have a contract for providing an out of hours emergency dental service.

The practice has three surgeries, all on the ground floor, a decontamination room, a reception and waiting area and a separate Dental panoramic X-ray room. The practice also has plans to expand and build extra surgeries and office space within the existing building.

There are four dentists, three dental nurses, four trainee dental nurses, one receptionist, a clinical manager, a personnel manager, an assistant manager and a general manager.

The practice also has staff for the out of hours services including: seven dentists, six dental nurses and two receptionists.

The practice is open:

Monday – Friday 08:00 – 17:30.

Due to the practice providing out of hours care, the service is accessible 365 days a year.

The practice manager is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons 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 received 25 are Quality Comment (CQC) cards providing feedback and spoke to three patients. The patients who provided feedback were positive about the care and treatment they received at the practice. They told us they were involved in all aspects of their care and found the staff to be friendly, caring and professional and they were treated with dignity and respect in a clean and tidy environment.

Our key findings were:

• There was a complaints system in place. Staff recorded complaints and cascaded learning to staff.
• Staff had received safeguarding training, knew how to recognise signs of abuse and how to report it.
• There were sufficient numbers of suitably qualified staff to meet the needs of patients.
• Staff had been trained to manage medical emergencies.
• Infection control procedures were in accordance with the published guidelines.
• Patient care and treatment was planned and delivered in line with evidence based guidelines, best practice and current regulations.
• Patients received clear explanations about their proposed treatment, costs, benefits and risks and were involved in making decisions about it.
• Patients were treated with dignity and respect and confidentiality was maintained.
• The appointment system met patients’ needs.
• The governance systems were effective.
• The practice sought feedback from staff and patients about the services they provided.

There were areas where the provider could make improvements and should:

• Implement a policy for lone working.
• Aim to have a documented action plan for all audits with guidance on improvements required and timescales for review.
• Review the practice’s protocols for the use of rubber dam for root canal treatment giving due regard to guidelines issued by the British Endodontic Society.
• Review how to disseminate safety alerts from the Medicines and Healthcare products Regulatory Agency (MHRA) within the practice more effectively.