You are here

Alpha Windmill (York) Limited

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Updated 14 January 2016

We carried out an announced comprehensive inspection on 12 November 2015 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

Alpha Windmill Orthodontic Dental Practice is situated in Acomb, York, North Yorkshire and is a limited company. The treatments, both NHS and private, range from fixed aesthetic braces to clear aligner treatments. The service is provided by four orthodontists who are supported by one orthodontic therapist, five dental nurses and a practice support manager. The practice is located on the ground floor and there are three surgeries, a reception area, a waiting room, a decontamination room, an X-ray room, a patient toilet and a separate accessible toilet. The practice is located close to local amenities and bus services. There is ample parking in the surrounding area.

The practice is open:

Monday – Thursday 08:30 – 17:30

Friday 08:00 – 16:30

The operations manager 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 eight CQC comment cards that had been completed by patients. The three patients and their relatives we spoke with were very 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 very friendly, kind, caring, understanding and they were always treated with dignity and respect.

Our key findings were:

  • The practice had systems to assess and manage risks to patients, including infection prevention and control, health and safety, safeguarding, recruitment and the management of medical emergencies.
  • The orthodontist carried out an assessment in line with recognised guidance from the British Orthodontic Society (BOS).
  • Patients told us they 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 a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients.

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

  • Review the fire risk assessment and implement a new assessment as soon as possible.
Inspection areas

Safe

No action required

Updated 14 January 2016

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

The practice had effective systems and processes in place to ensure that all care and treatment was carried out safely. For example, there were systems in place for infection prevention and control, clinical waste control, dental radiography and management of medical emergencies. All emergency equipment and medicines were in date and in accordance with the British National Formulary (BNF) and Resuscitation Council UK guidelines.

We saw staff had received training in infection prevention and control. There was a decontamination area and guidance for staff on effective decontamination of dental instruments.

Staff had received training in safeguarding patients and knew how to recognise the signs of abuse and who to report them to including external agencies such as the local authority safeguarding team.

Staff were appropriately recruited and suitably trained and skilled to meet patients’ needs and there were sufficient numbers of staff available at all times. Staff induction processes were in place and had been completed by all staff. It had been a few years since a new member of staff had joined the team but good supporting evidence was available for each member of staff.

We reviewed the legionella risk assessment dated February 2015 and evidence of regular water testing was being carried out in accordance with the assessment.

Effective

No action required

Updated 14 January 2016

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

Consultations were carried out in line with best practice guidance from the British Orthodontic Society (BOS). Patients received a comprehensive assessment of their orthodontic and dental needs. Explanations were given to patients in a way they understood and risks, benefits, options and costs were explained. The practice liaised with the referring dentist to ensure patients dental health was maintained throughout treatment.

The practice followed best practice guidelines when delivering dental care. These included guidance from the Faculty of General Dental Practice (FGDP) and NICE. The practice focused on prevention and the dentists were aware of the ‘Delivering Better Oral Health' toolkit (DBOH) with regards to fluoride application and oral hygiene advice.

Patients’ dental care records provided contemporaneous information about their current dental needs and past treatment. The patients’ dental care records we looked at with the orthodontist included discussions about treatment options, relevant X-rays including grading and justification. The practice monitored any changes to the patients’ oral health and made adjustments to treatments accordingly.

Staff were registered with the General Dental Council (GDC) and maintained their registration by completing the required number of hours of continuing professional development (CPD). Staff were supported to meet the requirements of their professional registration.

Staff understood the Mental Capacity Act 2005 and offered support when necessary. Staff were aware of Gillick competency in relation to children under the age of 16. Staff were supported to deliver effective care through training, peer support, practice manager meetings and practice meetings.

Caring

No action required

Updated 14 January 2016

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

We observed privacy and confidentiality were maintained for patients using the service on the day of the inspection. We looked at CQC comment cards patients had completed prior to the inspection and spoke with patients. Patients and their relatives spoke highly of the care they received from the practice. They commented they were treated with, kindness, respect and dignity while they received treatment.

Staff described to us how they ensured there was sufficient time to explain the care and treatment they were providing in a way patients understood. Patients and their relatives confirmed they felt fully involved in their treatment, it was explained to them, and they were listened to and not rushed.

Responsive

No action required

Updated 14 January 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. The registered manager told us allocated emergency slots were available or a patient could attend at the start or end of a session to be seen. Patients and their relatives commented they could access treatment for urgent and emergency care when required and were always seen within 24 hours. There were clear instructions for patients requiring urgent care when the practice was closed.

There was a procedure in place for acknowledging, recording, investigating and responding to complaints and concerns made by patients. This system was used to improve the quality of care. The practice was open and transparent in how they managed complaints, for example patients were given an apology if an error was made.

Well-led

No action required

Updated 14 January 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. The registered manager was responsible for the day to day running of the practice and also delegated tasks to the practice support manager.

Staff reported that the registered manager was approachable; they felt supported in their roles and were freely able to raise any issues or concerns with them at any time. The culture within the practice was seen by staff as open and transparent. Staff told us that they enjoyed working there.

The practice regularly undertook patient satisfaction surveys and were also undertaking the NHS Family and Friends Test. The practice regularly sought feedback from patients in the form of a satisfaction survey in order to improve the quality of the service provided.

The practice held regular staff meetings which were minuted, gave everybody an opportunity to openly share information and discuss any concerns or issues which had not already been addressed during their daily interactions.

The practice undertook various audits to monitor their performance and help improve the services offered.