You are here

Inspection Summary


Overall summary & rating

Updated 18 May 2018

We carried out this announced inspection on 2 May 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a CQC inspector who was supported by a specialist dental adviser.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

These questions form the framework for the areas we look at during the inspection.

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

Spadental Ledbury is located close to Ledbury town centre and provides private treatment to patients of all ages.

There is access available with a portable ramp for people who use wheelchairs and those with pushchairs. Car parking spaces are available on the opposite side of the road to the practice. Car parking spaces for blue badge holders are available in nearby pay and display car parks.

The dental team includes the principal dentist, two dental nurses (one of whom covers reception), a dental hygienist and the practice manager. The practice has two treatment rooms.

The practice is part of an organisation which includes two practices in Herefordshire. These are owned by the principal dentist. As a condition of registration the practices must have a person registered with the Care Quality Commission as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run. The registered manager at Spadental Ledbury was the principal dentist.

On the day of inspection we collected 30 CQC comment cards filled in by patients and looked at recent patient satisfaction survey responses. This information gave us a positive view of the practice.

During the inspection we spoke with the principal dentist, two dental nurses and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday: 9am to 5pm

Tuesday: 9am to 5pm

Wednesday: 9am to 5pm

Thursday: 9am to 1pm

Friday: 9am to 5pm

Our key findings were:

  • The practice appeared clean and well maintained.
  • The practice had infection control procedures which reflected published guidance.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available, with the exception of a self-inflating bag with reservoir for a child and clear face masks (sizes 0, 1, 2 and 4). These were ordered and replaced the day after our inspection.

  • The practice had systems to help them manage risk and had implemented comprehensive risk assessments, with the exception of a sharps risk assessment. We were sent a copy of the sharps risk assessment the following day.
  • The practice staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
  • The practice had thorough staff recruitment procedures.
  • The clinical staff provided patients’ care and treatment in line with current guidelines.
  • Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • The practice was providing preventive care and supporting patients to ensure better oral health.
  • The appointment system met patients’ needs. Patients could access routine treatment and urgent and emergency care when required at one of the two practices.
  • The practice had effective leadership and culture of continuous improvement.
  • Staff felt involved and supported and worked well as a team.
  • The practice asked staff and patients for feedback about the services they provided.
  • The practice staff dealt with complaints positively and efficiently.
  • The practice staff had suitable information governance arrangements.

There were areas where the provider could make improvements. They should:

  • Review the practice’s infection control procedures and protocols taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’. In particular by completing a sharps risk assessment and undertaking infection control audits on a six monthly basis.
Inspection areas

Safe

No action required

Updated 18 May 2018

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

The practice had systems and processes to provide safe care and treatment. They used learning from incidents and complaints to help them improve.

Staff received training in safeguarding and knew how to recognise the signs of abuse and how to report concerns. The practice had detailed contact information for local safeguarding professionals and relevant policies and procedures were in place.

The practice completed infection control audits on an annual basis rather than in line with recognised guidance which stipulates six monthly. The latest audit undertaken in September 2017 showed the practice was meeting the required standards. We were informed that these would be undertaken on a six monthly basis moving forward. An infection control audit was completed following our inspection which showed the practice was meeting the required standards.

Staff were qualified for their roles and the practice completed essential recruitment checks. We looked at five recruitment files and found that an identity document was not available for one staff member; we were informed this was held at the other practice and would be placed on file.

Premises and equipment were clean and properly maintained. The practice followed national guidance for cleaning, sterilising and storing dental instruments.

The practice protected staff and patients with guidance available for staff on the Control Of Substances Hazardous to Health (COSHH) Regulations 2002. Copies of manufacturers’ product safety data sheets were held for all materials and the practice were in the process of completing risk assessments for biological agents such as blood and saliva. This information was stored in a designated COSHH file and the completed risk assessment for biological agents was sent to us the following day.

The practice had suitable arrangements for dealing with medical and other emergencies. Appropriate medicines and life-saving equipment were available, with the exception of a self-inflating bag with reservoir for a child and clear face masks (sizes 0, 1, 2 and 4). These were ordered and replaced the day after our inspection.

Effective

No action required

Updated 18 May 2018

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

the relevant regulations.

The dentists assessed patients’ needs and provided care and treatment in line with recognised guidance. Patients described the treatment they received as excellent, relaxing and never rushed. The dentists discussed treatment with patients so they could give informed consent and recorded this in their records.

Patients commented that informative explanations of treatment were always given by their dentist.

The practice had clear arrangements when patients needed to be referred to other dental or health care professionals.

The practice supported staff to complete training relevant to their roles and had systems to help them monitor this.

Caring

No action required

Updated 18 May 2018

We found that this practice was providing caring services in accordance with

the relevant regulations.

We received feedback about the practice from 30 people. Patients were positive about all aspects of the service the practice provided. They told us staff were always helpful, professional and first class. We observed the dental nurse and practice manager rush to open the door for a patient with limited mobility and escort them into the waiting room.

They said that they were given informative explanations of treatment options and said their dentist listened to them. Patients commented that they made them feel at ease, especially when they were anxious about visiting the dentist.

We saw that staff protected patients’ privacy and were aware of the importance of confidentiality. Patients said staff treated them with dignity and respect. During the inspection we saw staff showed a caring and respectful attitude towards patients.

Responsive

No action required

Updated 18 May 2018

We found that this practice was providing caring services in accordance with

the relevant regulations.

We received feedback about the practice from 30 people. Patients were positive about all aspects of the service the practice provided. They told us staff were always helpful, professional and first class. We observed the dental nurse and practice manager rush to open the door for a patient with limited mobility and escort them into the waiting room.

They said that they were given informative explanations of treatment options and said their dentist listened to them. Patients commented that they made them feel at ease, especially when they were anxious about visiting the dentist.

We saw that staff protected patients’ privacy and were aware of the importance of confidentiality. Patients said staff treated them with dignity and respect. During the inspection we saw staff showed a caring and respectful attitude towards patients.

Well-led

No action required

Updated 18 May 2018

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

the relevant regulations.

The practice had arrangements to ensure the smooth running of the service. These included systems for the practice team to discuss the quality and safety of the care and treatment provided. There was a clearly defined management structure and staff felt supported and appreciated.

The practice team kept complete patient dental care records which were, clearly written or typed and stored securely.

The practice monitored clinical and non-clinical areas of their work to help them improve and learn. This included asking for and listening to the views of patients and staff.