Archived: Woodlands Dental Practice

Updated 25 October 2016

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 took place on 1 August 2016 and was led by a CQC Inspector assisted by a dental specialist adviser.

Prior to the inspection we asked the practice to send us some information which we reviewed. This included details of complaints they had received in the last 12 months, their latest statement of purpose, and details of their staff members including their qualifications and proof of registration with their professional body. We also reviewed information we held about the practice.

During the inspection we spoke with the registered manager, practice manager, dentists, dental nurse and receptionist. We reviewed policies, procedures and other documents and observed procedures.

We reviewed four CQC comment cards which we had sent prior to the inspection, for patients to complete about the services provided at the practice and spoke with two patients.

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 25 October 2016

We carried out an announced comprehensive inspection on 1 August 2016 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 this practice was not providing safe care in accordance with the relevant regulations.

Are services effective?

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

Are services caring?

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

Are services responsive?

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

Are services well-led?

We found this practice was not providing well-led care in accordance with the relevant regulations.

Background

The Woodlands Dental Practice is located close to the centre of Wellington and comprises an entrance off the main street shared with the upstairs residential accommodation. The practice located on the ground floor comprises a reception and waiting room, one treatment room, toilet and small basement. Parking is available nearby in the street outside the practice. The practice is accessible to patients with disabilities, impaired mobility and to wheelchair users via the use of a mobile aluminium ramp.

The surgery provides a full range of dental services to patients of all ages including preventative treatments, implants and full mouth reconstructions on a private basis to adults. It has an NHS provision for children only.

The opening times are Monday and Tuesday 9.30am to 5.30pm, Wednesday and Thursday 9.00am to 1.00pm and Friday 9.00am to 5.00pm. The practice is staffed by a practice manager (part time), two part time dentists, one dental nurse, and a receptionist.

The practice is registered with the Care Quality Commission (CQC) as a limited company and the provider is the registered manager. 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.

We received feedback from six patients during the inspection about the services provided. Patients commented they found the practice exemplary and staff were welcoming, friendly kind and caring. Several patients commented that staff go out of their way to help. Patients commented they were always given good and helpful explanations about dental treatment and the dentists listened to them. Patients commented the practice was clean and comfortable.

Our key findings were:

• There were sufficient numbers of suitably qualified and skilled staff to meet the needs of patients.

• Staff had been trained to deal with medical emergencies, and emergency medicines and equipment were available.

• The premises and equipment appeared clean and well maintained.

• Patients’ needs were assessed, and care and treatment were delivered, in accordance with current legislation, standards and guidance.

• Patients received information about their care, proposed treatment, costs, benefits and risks and were involved in making decisions about it.

• Opportunities for training and learning were available for staff.

• Patients were treated with kindness, dignity and respect, and their confidentiality was maintained.

• The appointment system met the needs of patients, and emergency appointments were available.

• Services were planned and delivered to meet the needs of patients and reasonable adjustments were made to enable patients to receive their care and treatment.

• The practice gathered the views of patients and took into account patient feedback.

• Improvements were required to ensure staff followed national guidance about infection prevention and control.

• Governance arrangements in place were not effective to facilitate the smooth running of the service and there was no source of evidence audits were being used for continuous improvements.

• There was not an effective system to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients, staff and visitors.

• Improvements were required to ensure there was an effective appraisal and performance review system for staff.

There were areas where the provider MUST make improvements :

• Ensure an effective system is established to assess, monitor and mitigate the various risks arising from undertaking the regulated activities.

• Ensure the practice's recruitment policy and procedures are suitable and the recruitment arrangements are in line with Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 to ensure necessary employment checks are in place for all staff and the required specified information in respect of persons employed by the practice is held.

• Ensure the storage of records relating to people employed and the management of regulated activities is in accordance with current legislation and guidance.

• Ensure audit protocols reflect the need to document learning points which are then shared with all relevant staff. Ensure the resulting improvements can be demonstrated as part of the audit process.

• Ensure the practice’s sharps handling procedures and protocols are compliant with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013

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

• Review the practice’s infection control procedures and protocols taking into account 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 arrangements for receiving and responding to patient safety alerts, recalls and rapid response reports issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and through the Central Alerting System, as well as from other relevant bodies such as Public Health England and the Department of Health.

• Review the practice protocols for medicines management and ensure all medicines are stored securely and where relevant are safely destroyed.

• Review the practice policy and the storage of products identified under the Control of Substances Hazardous to Health (COSHH) 2002 Regulations to ensure a risk assessment is undertaken and the products are stored securely.

• Review policies relating to fire management and implement regular fire equipment checking, training and drills for all staff.

• Review the current performance review systems and establish an effective process for the on-going assessment and supervision of all staff.