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Inspection report

Date of Inspection: 15 July 2013
Date of Publication: 17 August 2013
Inspection Report published 17 August 2013 PDF | 80.92 KB

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 15 July 2013, observed how people were being cared for and talked with people who use the service. We talked with staff.

Our judgement

The provider had an effective system to regularly assess and monitor the quality of service that patients received. The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of patients who use the service and others.

Reasons for our judgement

Patients who used the service were asked for their views about their care and treatment and they were acted upon. We looked at the results of a patient survey conducted in 2011. We saw that the patients who responded to the survey had given positive feedback. The practice sought constant feedback from patients by using a suggestion box. In addition the receptionist kept a comments book recording verbal comments made by patients. There was evidence that the practice acted upon the feedback from patients because we saw that during the patient survey in 2011 some patients had requested a change in opening hours. The dentist said “We now open earlier on a Wednesday morning, starting at 8am. We brought this in about a year ago and it’s been quite successful in terms of take up”.

There was some evidence that the practice used audits to inform and improve patient care. The practice had undertaken an ethnicity audit following attendance at an equality and diversity training course. This had identified that all of the patients sampled spoke English as their first language and therefore translation services were not required at that time. The practice were in the process of auditing medical histories to ensure that medical history forms were completed every year. The practice had completed audits of infection control at the required frequency stated in the decontamination of dental practices guidance issued by The Department of Health. We looked at the results of the last two audits and saw that changes had been implemented. For example we observed that reusable instrument trays were now put through the sterilization process, which had not happened previously.

We saw the practice complaints policy. There was a notice in the waiting area stating that if a patient wished to make a complaint staff would be able to provide further details. The provider may find it useful to note that the complaints procedure was not available to patients who did not wish to make staff aware that they wanted to complain. We enquired about complaints received within the last year. There had been one formal complaint to an external complaints organisation which was being investigated at the time of our visit. The comments book, held by the receptionist, had details of a complaint over the phone. It involved a relative questioning a dental payment plan that had not been cancelled. The relative had accepted that it was their responsibility to cancel the dental plan, which they had not done. However the practice had offered a six month refund of the payment plan as a gesture of goodwill. The receptionist told us that patient comments were recorded in the book and on the electronic patient records so that all staff were aware of patient preferences or views. We could see that the practice took account of complaints and comments to improve the service.

We looked at the accident and incident reports. We found two accidents involving staff injuring themselves in the last three years. Details of advice given to staff, including highlighting of relevant policies regarding PPE were included in the records. There had been one recorded accident involving a patient outside of the practice building. The practice had raised this with the company who owned the grounds so that they could investigate the incident and make changes if necessary. There was evidence that learning from incidents took place and appropriate changes were implemented.