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Inspection Summary


Overall summary & rating

Updated 19 July 2019

We carried out this announced inspection on 18 June 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

Almondbury Dental Practice is in Huddersfield and provides NHS and private treatment to adults and children.

The practice has a portable ramp to facilitate access to the practice for wheelchair users. Car parking is available near the practice.

The dental team includes five dentists, six dental nurses, (one of whom is a trainee), one dental hygiene therapist, one receptionist and two practice managers. The practice has four treatment rooms.

The practice is owned by a company 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 Almondbury Dental Practice is the principal dentist.

On the day of inspection, we collected 45 CQC comment cards filled in by patients.

During the inspection we spoke with three dentists, three dental nurses, the receptionist and both practice managers. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday, Wednesday and Thursday from 8:00am to 5:30pm

Tuesday from 8:00am to 8:30pm

Friday from 8:00am to 5:00pm

Saturday 9:00am to 12:00pm (one per month)

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.
  • The practice had systems to help them manage risk to patients and staff. Improvements could be made to the process for ensuring equipment is maintained according to manufacturer’s guidance.
  • The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • The provider had thorough staff recruitment procedures. Improvements could be made to the process for obtaining Disclosure and Barring Service (DBS) checks at the point of application.
  • 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 were providing preventive care and supporting 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 patients for feedback about the services they provided.
  • The provider dealt with complaints positively and efficiently.
  • The provider had suitable information governance arrangements.

There were areas where the provider could make improvements. They should:

  • Review the practice's systems for checking and monitoring equipment taking into account relevant guidance and ensure that all equipment is well maintained.
  • Review the practice's recruitment procedures to ensure that appropriate checks are completed prior to new staff commencing employment at the practice. In particular, DBS checks.
  • Review the practice’s protocols to ensure audits of radiography are carried out for all clinicians and infection prevention and control audits are undertaken at regular intervals to improve the quality of the service.
Inspection areas

Safe

No action required

Updated 19 July 2019

We found that this practice was providing safe care in accordance with the relevant regulations.

The practice had systems and processes to provide safe care and treatment. They used learning from incidents and complaints to help them improve.

Staff received training in safeguarding people and knew how to recognise the signs of abuse and how to report concerns.

Staff were qualified for their roles and the practice completed most essential recruitment checks. The practice had relied upon DBS checks from previous employers which were more than three months old at the point of application. We were told this would be addressed.

Premises and equipment were clean. The compressor was now overdue its regular service. This was addressed on the day of inspection and an appointment was booked.

The practice followed national guidance for cleaning, sterilising and storing dental instruments.

Staff had received training in how to deal with medical and other emergencies.

Effective

No action required

Updated 19 July 2019

We found that this practice was providing effective care in accordance with the relevant regulations.

The dentists assessed patients’ needs and provided care and treatment in line with recognised guidance. Patients described the treatment they received as very good, efficient and excellent. The dentists discussed treatment with patients so they could give informed consent and recorded this in their records.

The practice had clear arrangements when patients needed to be referred to other dental or health care professionals.

The provider supported staff to complete training relevant to their roles and had systems to help them monitor this.

The practice was a member of a ‘good practice’ certification scheme. This demonstrated a commitment to developing and maintaining a consistent quality of service for patients.

Caring

No action required

Updated 19 July 2019

We found that this practice was providing caring services in accordance with the relevant regulations.

We received feedback about the practice from 45 people. Patients were positive about all aspects of the service the practice provided. They told us staff were pleasant, professional and kind.

They said that all treatments were explained clearly and said their dentist listened to them. Patients commented that they made them feel at ease, especially when they were anxious about visiting the dentist.

We saw that staff protected patients’ privacy and were aware of the importance of confidentiality. Patients said staff treated them with dignity and respect.

Responsive

No action required

Updated 19 July 2019

We found that this practice was providing responsive care in accordance with the relevant regulations.

The practice’s appointment system took account of patients’ needs. Patients could get an appointment quickly if in pain.

The practice had a portable ramp to facilitate access to the practice for wheelchair users. The practice had access to interpreter services and had arrangements to help patients with hearing loss.

The practice took patients views seriously. They valued compliments from patients and responded to concerns and complaints quickly and constructively.

Well-led

No action required

Updated 19 July 2019

We found that this practice was providing well-led care in accordance with the relevant regulations.

The practice had arrangements to ensure the smooth running of the service. These included systems for the practice team to discuss the quality and safety of the care and treatment provided. There was a clearly defined management structure and staff felt supported and appreciated.

The practice team kept complete patient dental care records which were, clearly written or typed and stored securely.

The provider monitored clinical and non-clinical areas of their work to help them improve and learn. We noted that the infection prevention and control audit was only carried out annually and the X-ray audit was not completed for all clinicians. We were told that these would be addressed. The service asked for and listened to the views of patients and staff.