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Inspection Summary


Overall summary & rating

Updated 20 January 2017

We carried out an announced comprehensive inspection on 25 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 Dr Shenas Dental Clinc and provides private dental services. The opening hours for the practice were Monday to Friday 8.00am to5.30pm.

The premises consist of a treatment rooms, that encompasses the decontamination, a waiting areas and reception area.

The practice comprises of a principal dentist, a dentist, a nurse and a receptionist.

The principal dentist is registered with the Care Quality Commission (CQC) as an individual registered person. 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 asked patients to complete CQC comment cards and we spoke to patients on the day of the inspection. s.We received feedback from 14 patients. The patients who provided feedback were positive about the care and treatment they received at the practice. They told us they were involved in all aspects of their care and found the staff to be caring and helpful and they were treated with care, dignity and respect.

Our key findings were:

  • There were effective processes in place to reduce and minimise the risk and spread of infection.
  • Patients’ needs were assessed and care was planned in line with current guidance such as from the National Institute for Health and Care Excellence (NICE) Patients were involved in their care and treatment planning.
  • There was appropriate equipment for staff to undertake their duties and equipment was well maintained.
  • Staff were trained in and there was appropriate equipment for them to respond to medical emergencies.
  • Patients told us that staff were caring and treated them with dignity and respect.
  • Patients indicated that they felt they were listened to and that they received good care from a helpful and caring practice team.
  • There were processes in place for patients to give their comments and feedback about the service including making complaints and compliments.

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

  • Review the practice’s system for the recording, investigating and reviewing incidents or significant events with a view to preventing further occurrences and, ensuring that improvements are made as a result

  • Review the protocol for completing accurate, complete and detailed records relating to employment of staff.

  • 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 it’s responsibilities as regards to the Control of Substance Hazardous to Health (COSHH) Regulations 2002 and, ensure all documentation is up to date and staff understand how to minimise risks associated with the use of and handling of these substances.
  • Review availability of medicines and 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.

Inspection areas

Safe

No action required

Updated 20 January 2017

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

There were systems in place to help ensure the safety of staff and patients. These included policies for safeguarding children from abuse, maintaining the required standards of infection prevention and control and maintenance of equipment used at the practice.

The practice assessed risks to patients and managed these well. We found that staff were trained and there was appropriate equipment to respond to medical emergencies. In the event of an incident or accident occurring, the practice had a system in place to document, investigate and learn from it. However, improvements could be made in regards the recording of incidents. Improvements could also be made in regards to the recording of character references for staff.

Effective

No action required

Updated 20 January 2017

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

The practice followed guidance, such as that issued by National Institute for Health and Care Excellence (NICE). Patients were given appropriate information to support them to make decisions about the treatment they received. The practice kept detailed dental care records of treatments carried out and monitored any changes in the patient’s’ medical and oral health. Patients were given health promotion advice appropriate to their individual oral health needs such as smoking cessation advice where appropriate.

Staff were supported by the practice in maintaining their continuing professional development (CPD) and were meeting the requirements of their professional registration. However improvements could be made in regards to understanding of the MCA.

Caring

No action required

Updated 20 January 2017

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

The patient feedback we received was very positive about the service provided by the practice. We observed that staff treated patients with dignity and respect. We found that dental care records were stored securely, and patient confidentiality was well maintained.

Responsive

No action required

Updated 20 January 2017

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

Patients had good access to routine and emergency appointments at the practice. There was sufficient well maintained equipment to meet the dental needs of their patient population. Patients were given the opportunity to give feedback through the practices own feedback from patients through social media. There was a complaints policy.

Well-led

No action required

Updated 20 January 2017

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

There was a vision for the practice that was shared with the staff. Staff told us they felt supported and were clear about their areas of responsibility.

Staff told us regular meetings were held to discuss issues in the practice and update on things affecting the practice.

The quality audits undertaken at the practice included infection control and radiography audits.