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Loughborough University Dental Practice

Inspection Summary


Overall summary & rating

Updated 7 January 2016

We carried out an announced comprehensive inspection on 29 October 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

The practice is based on the campus of Loughborough University. It has been located in its present site since it started in 1994 and consists of three treatment rooms, a central decontamination room, and a small patient waiting room at reception. The practice has pay and display parking on the University campus grounds where disabled parking is also available. The practice is a single storey building and there is easy access to the treatment rooms for patients using wheelchairs and those with limited mobility

There are three dentists and five dental nurses who also cover reception duties. The provider who is the principal dentist is also the practice manager. The current owner took over in 1994 and at the time of our inspection was going through the process of selling the practice to the two associate dentists in the practice.

The practice provides both NHS and private dental treatment to both adults and to children. The practice is open Monday to Thursday from 9.00am to 5.30pm and Friday 8.00am to 1.30pm.

The provider 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.

We received feedback from 49 patients about the services provided. All of the feedback reflected positive comments about the staff and the services provided. Patients commented that the practice was clean and tidy; they found the staff offered a friendly service and were helpful, kind and caring. They found the practice to be clean and tidy. They said explanations were clear and that they were always informed of what was happening which made the dental experience as comfortable as possible.

The practice was providing care which was safe, effective, caring, responsive and well-led in accordance with the relevant regulations.

Our key findings were:

  • Staff had received safeguarding training and knew the processes to follow to raise any concerns.
  • There were sufficient numbers of suitably qualified staff to meet the needs of patients.
  • Infection control procedures were in place and staff had access to personal protective equipment.
  • Patients’ care and treatment was planned and delivered in line with evidence based guidelines and current legislation.
  • Patients received clear explanations about their proposed treatment, costs, benefits and risks and were involved in making decisions about them.
  • Patients were treated with dignity and respect and confidentiality was maintained.
  • The appointment system met the needs of patients and waiting times were kept to a minimum.
  • There was an effective complaints system.
  • The practice was well-led and staff felt involved and worked as a team.
  • Staff had been trained to deal with medical emergencies and appropriate medicines and life-saving equipment were readily available and accessible.
  • Governance systems were effective although policies and procedures had not been reviewed for up to two years.
  • The practice staff and manager were unable to locate portable suction.
  • The practice did not record and analyse significant events.

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

  • Review availability of equipment to manage medical emergencies giving due regard to guidelines issued by the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.
  • Infection control process to be laminated and displayed for all staff to have access to and be practice specific.
  • Review the cleaning and sterilising process in relation to published guidance (HTM 01-05).
  • 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 the practice’s sharps procedures giving due regard to the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013
  • Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.
  • Review the practice protocols for the servicing and maintenance of equipment. Ensure a new contract for the servicing of the compressor is in place.
Inspection areas

Safe

No action required

Updated 7 January 2016

We found that this practice was providing care which was safe in accordance with

the relevant regulations.

The

practice did have effective systems and processes in place to ensure all care and treatment was carried out safely.

Staff had received training in safeguarding vulnerable adults and children, and they could describe the signs of abuse and were aware of the external reporting process. Staff were appropriately recruited and suitably trained and skilled to meet patient’s needs and there were sufficient numbers of staff available at all times.

Infection control procedures were in place and staff had received training although the staff we spoke with said that this was different to their process. Radiation equipment was suitably sited and used by trained staff only. Emergency medicines in use at the practice were stored safely and checked to ensure they did not go beyond their expiry dates however the practice did not have portable suction.

The practice did not have an incident reporting policy nor did they have a way to record significant events. Staff we spoke with were unable to identify what a significant event was other than needlestick injury.

Effective

No action required

Updated 7 January 2016

We found that this practice was providing effective care in accordance with

the relevant regulations.

Patients received an assessment of their dental care needs including taking a medical history. Explanations were given to patients in a way they understood and risks, benefits and options available to them. Staff were supported through training and opportunities for development. Patients were referred to other services in a timely manner. Staff had not received training in the Mental Capacity Act (MCA) 2005 and staff we spoke with were inconsistent with how the MCA principles applied to their roles. Not all staff were aware of Gillick competency in relation to children under the age of 16.

Caring

No action required

Updated 7 January 2016

We found that this practice was caring in accordance with

the relevant regulations.

Patients were treated with dignity and respect and their privacy maintained. Patient information and data was handled confidentially. We saw that treatment was clearly explained and patients were provided with treatment plans. Patients with urgent dental needs or pain were responded to in a timely manner, often on the same day.

Responsive

No action required

Updated 7 January 2016

We found that this practice was providing responsive care in accordance with

the relevant regulations.

Consultations were carried out in line with guidance from the National Institute for Health and Care Excellence (NICE). Patients received a comprehensive assessment of their dental needs including taking a medical history. Explanations were given to patients in a way they understood and risks, benefits, and options were explained.

Staff were supported through training and opportunities for development. Patients were referred to other services in a timely manner.

Well-led

No action required

Updated 7 January 2016

We found that this practice was providing well-led care in accordance with

the relevant regulations.

T

he practice staff were involved in leading the practice to deliver satisfactory care. Care and treatment records had been audited to ensure standards had been maintained. Staff were supported to maintain their professional development and skills. Clinical audits were taking place however the practice had not effectively used audits clinical or non clinical to monitor and improve the quality of care provided. The practice sought and acted upon the views of patients with a suggestion box and survey.