Archived: Westbourne Dental Practice

We carried out this announced inspection on 17 October 2017 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.

We told the NHS England Cheshire and Merseyside area team that we were inspecting the practice. We did not receive any information of concern from them.

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

Westbourne Dental Practice is located in a residential suburb of Prenton and provides dental care and treatment to adults and children on an NHS and privately funded basis.

The provider has installed a ramp to facilitate access to the practice for wheelchair users. The practice has six treatment rooms. Car parking is available at the practice.

The dental team includes a principal dentist, five associate dentists, a Foundation dentist, a dental hygienist, two dental hygiene therapists, eight dental nurses, two of whom are trainees, and two receptionists. The team is supported by a practice manager.

The practice is owned by an individual who is the principal dentist there. They 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 46 people during the inspection about the services provided. The feedback provided was positive about the practice.

During the inspection we spoke to three dentists, dental nurses, receptionists and the practice manager. We looked at practice policies, procedures and other records about how the service is managed.

The practice is open:

Monday to Thursday 9.00am to 6.00pm

Friday 9.15am to 5.00pm.

Our key findings were:

• The practice was clean and well maintained.
• The practice had infection control procedures in place which reflected published guidance.
• Staff knew how to deal with emergencies. Appropriate medical emergency medicines and equipment were available.
• Staff provided patients’ care and treatment in line with current guidelines.
• The practice had a procedure in place for dealing with complaints.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• The appointment system took patients’ needs into account. Dedicated emergency appointments were available.
• The practice had a leadership structure. Staff felt involved and supported and worked well as a team.
• The practice asked patients and staff for feedback about the services they provided.
• The practice had systems in place to help them manage risk. We observed that some of these risks were not assessed and managed effectively, including fire and Legionella.
• The practice had safeguarding processes in place and staff knew their responsibilities for safeguarding adults and children. Training had not been carried out for two members of staff.
• The practice had staff recruitment procedures in place. The required information was not available for one of the staff.

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

• Review the practice’s recruitment procedures for carrying out and recording recruitment checks and maintaining accurate, complete and detailed records relating to employment of staff.
• Review the practice’s systems for assessing, monitoring and mitigating the various risks arising from undertaking of the regulated activities, specifically in relation to fire, Legionella, staff vaccinations and domiciliary visits.
• Establish whether the practice is in compliance with its legal obligations under the Ionising Radiation Regulations 1999 and the Ionising Radiations (Medical Exposure) Regulations 2000.
• Review the protocols and procedures to ensure staff are up to date with their recommended training and their continuing professional development.
• Review the practice’s protocols in relation to the use of closed circuit television to ensure staff and patients are fully informed as to its purpose and their right to access footage.
• Review the storage of paper dental care records to ensure they are stored securely.