Archived: West End Manse Dental Care

Updated 28 November 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 was carried out on 1 November 2016 by a CQC inspector who was supported by a specialist dental adviser. During the inspection, we spoke with three dentists, two dental nurses and a receptionist. We reviewed policies, procedures and other documents relating to the management of the service. We received feedback from 30 patients about the quality of the service, which included comment cards and patients we spoke with during our inspection.

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 28 November 2016

We carried out an announced comprehensive inspection on 1 November 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 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

West End Manse Dental Surgery provides primarily NHS treatment to adults and children and serves about 18000 patients. The team consists of five dentists, 11 part-time dental nurses, a receptionist and administrator.

The practice is situated in a converted residential property and has five dental treatment rooms and a decontamination room for sterilising dental instruments. There is a waiting area, a reception area, office and staff room.

The practice is open from 8.45am to 6pm on Mondays and Fridays and from 8.45am to 5.15pm on Tuesday and Wednesdays. On Fridays it is open from 8.45am to 2pm.

At time of inspection, the principal dentist was registered with the Care Quality Commission (CQC) as an individual. 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.

Before the inspection we sent comment cards to the practice for patients to complete to tell us about their experience of the practice. We received feedback from 25 patients. These provided a very positive view of the service provided.

Our key findings were:

• Information from 25 completed Care Quality Commission comment cards gave us a positive picture of a friendly, professional and high quality service.

• The practice had good facilities and was well equipped to treat patients and meet their needs.

• The practice had systems to help ensure patient safety. These included safeguarding children and adults from abuse, maintaining the required standards of infection prevention and control, and responding to medical emergencies.

• Risk assessment was robust and action was taken to protect staff and patients.

• There were sufficient numbers of suitably qualified and competent staff. Members of the dental team were up-to-date with their continuing professional development and supported to meet the requirements of their professional registration.

• Patients’ needs were assessed and care was planned and delivered in line with current best practice guidance from the National Institute for Health and Care Excellence (NICE) and other published guidance.

• Staff felt well supported and were committed to providing a quality service to their patients.

• Recommendations form the practice’s legionella assessment had not been implemented to reduce the risk of bacterial growth

• The practice’s recruitment procedures were not robust.

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

• Review the practice’s legionella assessment and ensure that all recommendations are implemented.

• Review the practice's recruitment policy and procedures to ensure references for new staff are obtained.
• Review the security of prescription pads in the practice and ensure there are systems in place to monitor and track their use.