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Inspection report

Date of Inspection: 17 February 2014
Date of Publication: 18 March 2014
Inspection Report published 18 March 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, observed how people were being cared for and talked with people who use the service. We talked with staff.

Our judgement

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

Reasons for our judgement

Patients who use the service and their representatives were asked for their views about the care and treatment and they were acted on.

We spoke with four patients. They told us they were happy with the service. One patient said, “I’m very happy with it.” Another patient said, “I think he’s [the dentist is] absolutely excellent.”

One patient told us they had received a feedback form to complete. However, two patients told us they had not. One of these patients told us they felt it would be nice to feedback how happy they had been with the service and said, “I’ve been really, really happy.”

We saw that forms were available in the waiting area for patients to provide feedback on the service. We saw an analysis of patient feedback from 2013 and this was positive. We saw this included information about patients’ wishes for the practice to open on Saturdays and for text message reminders to be provided. We saw that the hygienist had started to work on Saturdays and text message reminders were used. This meant systems were in place for seeking feedback from patients and for taking action in response. The practice manager told us they analysed the feedback forms once a year, but were considering increasing the frequency of this. They also told us they read the feedback forms when received and would take immediate action when this was appropriate.

We also saw that a suggestions box was in the waiting area. This meant patients were provided with another mechanism for providing their views on the service.

Patients we spoke with told us they felt staff would listen to them and they would feel comfortable to make a complaint, but they did not wish to make a complaint. One patient said the service was, “Great. No complaints.” The provider may find it useful to note that one patient told us they had seen information about how to make a complaint, but some patients told us they did not know the process. However, we saw that a complaints procedure was on display in the corridor. Information was also in the practice information leaflet for patients.

The provider may find it useful to note that the complaints policy on display stated that complaints would be investigated speedily and efficiently, but also stated that investigations would normally be completed within six months. This meant there was a risk that patients would think that an investigation would be undertaken over a longer period of time than was likely. The dentist, who was also the provider, told us they would amend the timescale in the document.

The practice manager told us that only one complaint had been received and this was from 2012. We saw that information was recorded about the complaint and actions taken in response. This meant the service had systems in place for responding to complaints.

Staff we spoke with told us that practice meetings took place and we saw minutes from these meetings. This meant there were systems in place for staff to provide feedback on the service and for discussions to take place about the delivery of the service.

We saw that some audits were completed within the practice. We saw a radiographs audit from January 2014 to check the quality of radiographs. We also saw a record keeping audit from January 2013. The provider may find it useful to note that this had not been completed recently. However, an audit was planned. We looked at some records during our inspection and saw they were appropriate.

We also saw a hand hygiene audit from January 2014, which meant the service had checked that staff were carrying out appropriate hand washing techniques. Cleaning audits were also completed. We also saw a copy of an infection control audit that had been completed by the practice. However, the provider may find it useful to note that this had not been completed recently. This meant there was a risk that the practice might not identify infection control issues in a timely manner. However, we saw that the service had an audit tool to use and