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Inspection Summary


Overall summary & rating

Updated 23 March 2016

We carried out an announced comprehensive inspection on 9 February 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

Humber & Yorkshire CDA - Ilkley is situated in Ilkley, West Yorkshire. It offers mainly NHS treatment to patients of all ages but also offers private dental treatments. The services include preventative advice and treatment, routine restorative dental care, dental implants and specialist periodontal treatments.

The practice has two surgeries, a decontamination area with separate dirty and clean rooms, a waiting area and a reception area. The reception area, waiting area and both surgeries are on the ground floor. There is wheelchair access to the premises. There are accessible toilet facilities on the ground floor of the premises.

There are two dentists (one of whom provides dental implants and specialist periodontal treatments), one dental hygienist, two dental nurses (who also cover reception duties) and a practice manager.

The opening hours are Monday to Friday from 9-00am to 5-00pm. The practice is closed for lunch between 12-30pm to 1-30pm.

One of the practice owners 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.

During the inspection we spoke with three patients who used the service and reviewed two completed CQC comment cards. The patients were positive about the care and treatment they received at the practice. Comments included that the staff were polite, friendly and helpful.

Our key findings were:

  • The practice had systems in place to assess and manage risks to patients and staff including infection prevention, control and health and safety and the management of medical emergencies.
  • Staff were qualified and received training appropriate to their roles.
  • Patients were involved in making decisions about their treatment and were given clear explanations about their proposed treatment including costs, benefits and risks.
  • Oral health advice and treatment were provided in-line with the ‘Delivering Better Oral Health’ toolkit (DBOH).
  • We observed that patients were treated with kindness and respect by staff. Staff ensured there was sufficient time to explain fully the care and treatment they were providing in a way patients understood.
  • Patients were able to make routine and emergency appointments when needed.
  • The practice had a complaints system in place and there was an openness and transparency in how these were dealt with.
  • There was clearly defined management structure and staff told us that they felt supported, appreciated and comfortable to raise concerns or make suggestions.

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

  • Review the practice’s process for the storage of data from the autoclaves.
  • Review the arrangement of the hand washing sink in the decontamination room.
  • Document when the emergency drugs have been checked.
  • Review the practice’s procedure for the bagging of re-usable dental burs.
Inspection areas

Safe

No action required

Updated 23 March 2016

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

Staff told us they felt confident about reporting incidents, accidents and Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR).

Staff had received training in safeguarding at the appropriate level and knew the signs of abuse and who to report them to.

Staff were suitably qualified for their roles and the practice had undertaken the relevant recruitment checks to ensure patient safety.

Patients’ medical histories were obtained before any treatment took place. The dentists were aware of any health or medication issues which could affect the planning of treatment. Staff were trained to deal with medical emergencies. All emergency equipment and medicines were in date and in accordance with the British National Formulary (BNF) and Resuscitation Council UK guidelines. However, we noted that the dates of when the emergency drugs were checked was not documented.

The decontamination procedures were effective and the equipment involved in the decontamination process was regularly serviced and validated to ensure it was safe to use. However, we noted that the data from the autoclaves was not downloaded to secure storage.

Effective

No action required

Updated 23 March 2016

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

Patients’ dental care records provided comprehensive information about their current dental needs and past treatment. The practice monitored any changes to the patient’s oral health and made referrals for specialist treatment or investigations where indicated.

The practice followed best practice guidelines when delivering dental care. These included Faculty of General Dental Practice (FGDP), National Institute for Health and Care Excellence (NICE) and guidance from the British Society of Periodontology (BSP). The practice focused strongly on prevention and the dentists were aware of ‘The Delivering Better Oral Health’ toolkit (DBOH) with regards to fluoride application and oral hygiene advice.

Staff were encouraged to complete training relevant to their roles and this was monitored by the practice manager. The clinical staff were up to date with their continuing their professional development (CPD).

Referrals were made to secondary care services if the treatment required was not provided by the practice.

Caring

No action required

Updated 23 March 2016

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

During the inspection we spoke with three patients who used the service and reviewed two completed CQC comment cards. Patients commented that staff were polite, friendly and helpful. Patients also commented that they were involved in treatment options.

We observed the staff to be welcoming and caring towards the patients.

We observed privacy and confidentiality were maintained for patients using the service on the day of the inspection.

Staff explained that enough time was allocated in order to ensure that the treatment and care was fully explained to patients in a way which they understood.

Responsive

No action required

Updated 23 March 2016

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

The practice had an efficient appointment system in place to respond to patients’ needs. There were vacant appointments slots for urgent or emergency appointments each day.

Patients commented they could access treatment for urgent and emergency care when required. There were clear instructions for patients requiring urgent care when the practice was closed.

There was a procedure in place for responding to patients’ complaints. This involved acknowledging, investigating and responding to individual complaints or concerns. Staff were familiar with the complaints procedure and there was a dedicated complaints manager.

The practice was fully accessible for patients with a disability or limited mobility in order to access dental treatment.

Well-led

No action required

Updated 23 March 2016

We found that this practice was providing well-led care in accordance with the relevant regulations.

There was a clearly defined management structure in place and all staff felt supported and appreciated in their own particular roles. The practice manager was responsible for the day to day running of the practice.

The practice organised training for staff to ensure all staff were up to date with their continuous professional development as required by the General Dental Council.

The practice regularly audited clinical and non-clinical areas as part of a system of continuous improvement and learning.

There were good arrangements in place to share information with staff by means of monthly practice meetings and nurse meetings which were minuted for those staff unable to attend.

They were currently undertaking the NHS Friends and Family Test (FFT) and there was a comments box in the waiting room for patients to make suggestions to the practice.