Willerby Dental Care Limited

Updated 4 July 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 registered provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The inspection was carried out on 26 May 2016 and was led by a CQC Inspector and a specialist dental advisor.

We informed NHS England area team and Healthwatch North Yorkshire that we were inspecting the practice; however we did not receive any information of concern from them

The methods that were used to collect information at the inspection included interviewing staff, observations and reviewing documents.

During the inspection we spoke with the registered manager/principal dentist, the practice manager, the dental hygiene therapist and two dental nurses. We saw policies, procedures and other records relating to the management of the service. We reviewed 26 CQC comment cards that had been completed.

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 4 July 2016

We carried out an announced comprehensive inspection on 26 May 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

Willerby Dental Care Limited is located on Kingston Road, Willerby and provides dental treatment to NHS and private patients. The surgeries are all accessible by service users with restricted mobility. The practice is all on the ground floor and has ramp access at the front of the building. Car parking is available for three cars. The practice has a reception area, a waiting room, a decontamination room and separate sterilisation room connected by a hatch. There arepatient toilets , a staff room and office.

There are three dentists (the owner, and two associate dentists), a dental hygiene therapist and four dental nurses, one of which works on reception.

The practice is open:

Monday, Wednesday, Thursday and Friday 08:00 – 17:00

Tuesday 09:00 – 18:00

The principal dentist 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.

On the day of inspection we received 26 CQC comment cards providing feedback and spoke to three patients. The patients who provided feedback were very positive about the care and attention to treatment they received at the practice. They told us they were involved in all aspects of their care and found the staff to be polite, helpful, caring, and professional and they were treated with dignity and respect in a clean and tidy environment.

Our key findings were:

• Staff had received safeguarding training, knew how to recognise signs of abuse and how to report it.
• There were sufficient numbers of suitably qualified staff to meet the needs of patients.
• Staff had been trained to manage medical emergencies.
• Infection control procedures were in accordance with the published guidelines.
• Patient care and treatment was planned and delivered in line with evidence based guidelines, best practice and current regulations.
• Patients received clear explanations about their proposed treatment, costs, benefits and risks and were involved in making decisions about it.
• Patients were treated with dignity and respect and confidentiality was maintained.
• The appointment system met patients’ needs.
• The practice sought feedback from staff and patients about the services they provided.

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

• Review the weekly check protocol for the medical emergency drugs and equipment to ensure all equipment is in date and the recommended type.
• Review the practice protocol and ensure the practice implements a fire risk assessment.

• Review the practice’s protocol for undertaking audits of infection prevention and control, dental care records and X-rays at regular intervals to help improve the quality of service. The practice should also ensure all audits have documented learning points so the resulting improvements can be demonstrated.
• Review the complaints policy to make it accessible to patients, ensure all external agencies are referred to within the policy and time frames of when a response will be in place incorporated. Implement a process to track complaints more effectively. And ensure they have been responded to in line with the policy.
• Review the practice protocol for referrals ensuring adequate information is in place to treat patients’ requirements.
• Review the practice’s protocols for recording in the patients’ dental care records or elsewhere the reason for taking the X-ray and quality of the X-ray giving due regard to the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2000.