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Stella Maris Practice Limited

Inspection Summary


Overall summary & rating

Updated 15 November 2016

We carried out an announced comprehensive inspection on 13 September 2016 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

Stella Maris Dental Practice Limited is a dental practice providing general dental services on a private basis. Additional services include implant dentistry and orthodontics. The service is provided by three dentists, three dental hygienists and one dental therapist. They are supported by six dental nurses (three of whom are trainees), a practice manager and a receptionist. All of the dental nurses also carry out reception duties. A clinical dental technician also visits the practice on a weekly basis to provide prosthetic dentistry. Another dentist visits the practice on an ad hoc basis to provide complex oral surgery.

The practice is located on a main road near local amenities and bus routes. There is wheelchair access to the practice and car parking facilities. The premises consist of a waiting room, a reception area, an office, staff room/kitchen two treatment rooms and accessible toilet facilities on the ground floor. The first floor comprises of a decontamination room, three treatment rooms and a waiting area. There is also a designated area for taking X-rays. There is also a basement which is used as a storage area. The practice opening hours are from 9am to 5:45pm on Monday to Thursday and from 9am to 1pm on Fridays.

The provider operates the practice as a limited company and is the sole director and 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.

Twenty-eight patients provided feedback about the practice. We looked at comment cards patients had completed prior to the inspection and we also spoke with three patients. The information from patients was all complimentary. Patients were positive about their experience and they commented that staff were friendly, professional and welcoming.

Our key findings were:

  • The practice appeared clean and tidy on the day of our visit. Many patients also commented that this was their experience.
  • Patients told us they found the staff polite and friendly. Patients were able to make routine and emergency appointments when needed.
  • An infection prevention and control policy was in place. We saw the decontamination procedures followed recommended guidance.
  • The practice had systems to assess and manage risks to patients, including health and safety, safeguarding, safe staff recruitment and the management of medical emergencies. We identified some areas of improvement.
  • Dental professionals provided treatment in accordance with current professional guidelines.
  • There was appropriate equipment for staff to undertake their duties, and equipment was well maintained.
  • The practice had a complaints system in place.
  • Staff told us they felt well supported and comfortable to raise concerns or make suggestions.
  • The practice demonstrated that they undertook audits in infection control, radiography and dental care record keeping.

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

  • Review the practice’s system for the recording, investigating and reviewing incidents or significant events with a view to preventing further occurrences and ensuring that improvements are made as a result.
  • Review availability of medicines and 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 staff training in safeguarding ensuring it covers both children and adults and all staff are trained to an appropriate level for their role and aware of their responsibilities. The practice should also review the training, learning and development needs of individual staff members and have an effective process established for the ongoing assessment and supervision of all staff.
  • Review the practice's recruitment policy and procedures to ensure character references, DBS (Disclosure and Barring Service) checks and the assessment of related risks for new staff are requested and recorded suitably.
  • Review the protocols and procedures to ensure staff are up to date with their mandatory training and their Continuing Professional Development.
Inspection areas

Safe

No action required

Updated 15 November 2016

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

The practice had systems to assess and manage risks to patients. These included whistleblowing, complaints, safeguarding and the management of medical emergencies. It also had a recruitment process to help ensure the safe recruitment of staff. We identified areas where improvements were required and staff responded promptly to feedback.

Patients’ medical histories were obtained before any treatment took place. The dentist was aware of any health or medicines issues which could affect the planning of treatment.

The practice was carrying out infection control procedures as described in the ‘Health Technical Memorandum 01-05 (HTM 01-05): Decontamination in primary dental practices’.

Staff told us they felt confident about reporting accidents but no incidents had been documented. Staff were aware of the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR).

Effective

No action required

Updated 15 November 2016

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

The practice monitored any changes to the patients’ oral health and made referrals for specialist treatment or investigations where indicated. Explanations were given to patients in a way they understood and risks, benefits and options were explained. Record keeping was in line with guidance issued by the Faculty of General Dental Practice (FGDP).

The dentists followed national guidelines when delivering dental care. We found that preventative advice was given to patients in line with the guidance issued in the Department of Health publication 'Delivering better oral health: an evidence-based toolkit for prevention' when providing preventive oral health care and advice to patients. This is an evidence based toolkit used by dental teams for the prevention of dental disease in a primary and secondary care setting.

Caring

No action required

Updated 15 November 2016

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

On the day of the inspection we observed privacy and confidentiality were maintained for patients using the service. Patient feedback was completely positive about the care they received from the practice. Patients described staff as friendly and polite. Patients commented they felt involved in their treatment and it was fully explained to them. Nervous patients said they felt at ease here and the staff were supportive and understanding.

Responsive

No action required

Updated 15 November 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. They were usually able to see patients requiring urgent treatment within 24 hours. Patients were able to contact staff when the practice was closed and arrangements were subsequently made for these patients requiring emergency dental care.

The practice had a complaints process.

The practice offered access for patients with limited mobility.

Well-led

No action required

Updated 15 November 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 and staff we spoke with felt supported in their own particular roles.

There were systems in place to monitor the quality of the service including various audits. The practice used several methods to successfully gain feedback from patients.

The practice carried out audits such as radiography, dental care record keeping and infection control to help improve the quality of service.