Updated 14 September 2018
We carried out this announced inspection on 15 August 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 remotely 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
Ivory Dental Practice Limited is in the centre of Horsforth and provides private dental treatment for adults and children.
There is level access (via a portable ramp), for people who use wheelchairs and those with pushchairs. Car parking and public transport facilities are available near the practice.
The dental team includes four dentists, seven dental nurses, (one of whom is a trainee), three dental hygiene therapists, a practice manager, a care coordinator and two receptionists. The practice has four treatment rooms.
The practice is owned by company and as a condition of registration 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. At the time of the inspection the practice did not have a registered manager in post. We have written to the provider about this.
On the day of inspection, we collected 50 CQC comment cards filled in by patients.
During the inspection we spoke with one dentist, two dental nurses, the care coordinator, a receptionist and the practice manager. We looked at the practice’s policies and procedures and other records about how the service is managed.
The practice is open: Monday, Wednesday and Thursday 8:30am-7pm, Tuesday 9:30am-7pm, Friday 8am-5:30pm and Saturday 8:30am-5:30pm.
Our key findings were:
- The practice appeared clean and well maintained.
- The practice staff had infection control procedures which reflected published guidance. Infection control audits were not carried out at the recommended time intervals needed updating.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- The practice had systems to help them manage risk.
- The provider had staff recruitment procedures in place. Recruitment records were not always completed.
- The practice staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
- 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.
- The practice had effective leadership and a 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.
- Clinical and non-clinical audits were mostly completed. Radiographic audits were not always completed for each dentist.
- The practice staff had suitable information governance arrangements.
There were areas where the provider should make improvements.
- Review the practice's recruitment policy and procedures to ensure accurate, complete and detailed records are maintained for all staff.
- Review the practice’s protocols to ensure audits of radiography and infection prevention and control are undertaken at regular intervals to improve the quality of the service.