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Inspection report

Date of Inspection: 18 August 2014
Date of Publication: 9 September 2014
Inspection Report published 09 September 2014 PDF

Before people are given any examination, care, treatment or support, they should be asked if they agree to it (outcome 2)

Meeting this standard

We checked that people who use this service

  • Where they are able, give valid consent to the examination, care, treatment and support they receive.
  • Understand and know how to change any decisions about examination, care, treatment and support that has been previously agreed.
  • Can be confident that their human rights are respected and taken into account.

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 18 August 2014, observed how people were being cared for and talked with people who use the service. We talked with staff and reviewed information given to us by the provider.

Our judgement

Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes.

Reasons for our judgement

Before patients received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. During our visit we spoke with all the staff who were working at the practice that day. They explained how treatment options were discussed with their patients. We saw that patient records contained a record of the treatment options that had been discussed to enable patients to make informed decisions. We spoke with four patients who confirmed that they were always given sufficient information before consenting to their treatment. One patient told us; “Everything is explained in detail and [the costs] quoted fully”.

We saw that patients were given written, personalised information regarding their treatment. Patients signed to indicate they were happy with the treatment plan and associated costs. The forms contained clear information about the teeth requiring treatment and the materials to be used. During our visit we spoke with four patients who all told us that they understood the treatment they were consenting to and why it was necessary. Patients told us that the risks and benefits of treatment options had been explained in a way they could understand.

The practice had printed consent forms for various treatments they provided, such as tooth whitening, implants and extractions. These consent forms gave clear information for their patients about the treatment, why the treatment was necessary, the benefits and any possible risks.

One of the dentists at the practice provided treatment under inhalation sedation (IS). This is a form of sedation, a mixture of nitrous oxide and oxygen breathed through a nosepiece. This helps patients to feel relaxed and accept treatment. We saw that when patients agreed to IS they were given written information about the procedure and were required to attend a pre-treatment appointment to ensure they understood what was involved before signing to indicate their consent. We saw that these discussions were documented in the patient record. This form of sedation was often used to help children accept dentistry. We saw that all discussions with the child and their parent were documented and consent forms signed by the parent were completed before any treatment took place.

The practice had a policy on consent which had been regularly reviewed. It documented that patients could change their minds and withdraw their consent at any time and this principle was understood by all staff. However this policy did not provide guidance for staff about the legal requirements relating to consent for patients who lacked capacity. We discussed this with the dentist who was also the provider of this service. They understood the principles of the Mental Capacity Act (2005) and were clear about the actions they would take should they have occasion to question the capacity of any of their patients to provide consent to treatment.