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Mr Andrew David Morgan - Henley

Inspection Summary


Overall summary & rating

Updated 20 April 2017

We carried out an announced comprehensive inspection on 14 March 2017 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

Damira Dental Studios Henley is a dental practice providing NHS and private treatment for both adults and children. The practice is based in commercial premises in Henley on Thames a town in Oxfordshire.

The practice has three dental treatment rooms all of which are based on the first floor and a separate decontamination area used for cleaning, sterilising and packing dental instruments. Patients with limited mobility are sign-posted to nearby dental services with ground floor access.

The practice employs three dentists, one hygienist, two nurses, two trainee nurses, two receptionists and area manager who is managing the practice for part of the week while a new manager is recruited.

The practice’s opening hours are between 8am and 6.30pm from Monday to Friday.

There are arrangements in place to ensure patients receive urgent medical assistance when the practice is closed. This is provided by an out-of-hours service, via 111.

As a condition of their registration with the CQC, the provider is required to ensure that the regulated activities are managed by an individual who is registered as a manager in respect of those activities at Henley Dental Care. At the time of the inspection there was no registered manager in place.

The registered manager resigned the week before our visit and an area manager was undertaking the role of the registered manager while a replacement was found.

Before the inspection, we sent Care Quality Commission comment cards to the practice for patients to complete to tell us about their experience of the practice. We received feedback from 11 patients. These provided a positive view of the services the practice provides. Patients commented on the high quality of care, the caring nature of all staff, the cleanliness of the practice and the overall high quality of customer care.

We obtained the views of nine patients on the day of our inspection.

Our key findings were:

  • We found that the practice ethos was to provide patient centred dental care in a relaxed and friendly environment.
  • There were generally appropriate medicines and life-saving equipment were readily available in accordance with current guidelines.
  • The practice appeared clean and well maintained.
  • There was appropriate equipment for staff to undertake their duties, and equipment was well maintained.
  • Infection control procedures were robust and the practice followed published guidance.
  • The practice had a safeguarding lead with effective processes in place for safeguarding adults and children living in vulnerable circumstances.
  • There was a process in place for the reporting and shared learning when untoward incidents occurred in the practice.
  • Dentists provided dental care in accordance with current professional and National Institute for Care Excellence (NICE) guidelines.
  • The service was aware of the needs of the local population and took these into account in how the practice was run.
  • Patients could access treatment and urgent and emergency care when required.
  • Staff received training appropriate to their roles and were supported in their continued professional development (CPD) by the company.
  • Patient feedback before and during our inspection gave us a positive

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

  • Review the security of the decontamination room which contained substances subject to COSHH regulations to prevent unauthorised access by the public.
  • 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.
  • Review the current staffing arrangements to ensure all dental care professionals are adequately supported by a trained member of the dental team when treating patients in a dental setting.
  • Review its responsibilities to the needs of people with a disability and the requirements of the equality Act 2010 with respect to the provision of a hearing loop for patients who are hard of hearing.
  • Review display of information related to staff working at the practice taking into account guidance issued by the General Dental Council.
Inspection areas

Safe

No action required

Updated 20 April 2017

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

the relevant regulations.

The practice had arrangements in place for essential areas such as infection control, clinical waste control and dental radiography (X-rays). We found that all the equipment used in the dental practice was well maintained.

The practice took its responsibilities for patient safety seriously and staff were aware of the importance of identifying, investigating and learning from patient safety incidents.

Staff had received safeguarding training and were aware of their responsibilities regarding safeguarding children and vulnerable adults.

Effective

No action required

Updated 20 April 2017

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

The dental care provided was evidence based and focused on the needs of the patients. The practice used current national professional guidance including that from the National Institute for Health and Care Excellence (NICE) to guide their practice.

We saw examples of positive teamwork within the practice and evidence of good communication with other dental professionals. The staff received professional training and development appropriate to their roles and learning needs.

Caring

No action required

Updated 20 April 2017

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

We obtained the views of nine patients on the day of our visit. These provided a positive view of the service the practice provided.

All of the patients commented that the quality of care was very good. Patients commented on friendliness and helpfulness of the staff and dentists were good at explaining the treatment that was proposed.

Responsive

No action required

Updated 20 April 2017

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

The service was aware of the needs of the local population and took these into account in how the practice was run.

Patients could access treatment and urgent and emergency care when required. The practice provided patients with access to telephone interpreter services when required.

Although the practice was situated on the first floor of the building, patients who found stairs a barrier were sign-posted to nearby dental services with ground floor access.    

Well-led

No action required

Updated 20 April 2017

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

the relevant regulations.

The governance arrangements for this location consisted of a practice manager who was responsible for the day to day running of the practice. The practice manager resigned the week before our inspection and an area manager was undertaking the role of practice manager whilst a replacement was recruited.

The practice maintained a system of policies and procedures; however there were shortfalls within the system. This included systems to mitigate the risks relating to fire, the storage of controlled drugs used for intra-venous sedation and the collation of staff training records. We have since received evidence to confirm the shortfalls have been addressed.

There was a no blame culture in the practice. We saw evidence of systems to identify staff learning needs which were underpinned by an appraisal system and a programme of clinical audit. Staff working at the practice were supported to maintain their continuing professional development as required by the General Dental Council.

All the staff we met said that they were happy in their work and the practice was a good place to work.