Updated 27 November 2019
We carried out this announced inspection on 11 November 2019 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
Alpha Windmill (Bedale) Limited provides NHS orthodontic treatment with some private treatment for adults and children.
The practice shares the building with an Alpha Studio dental practice. There is level access for people who use wheelchairs and those with pushchairs. The orthodontic practice has one treatment room on the first floor, with two dental chairs. If required an alternative ground floor surgery can be used.
There is a car park and local transport facilities nearby.
The dental team includes four orthodontists, three dental nurses, one dental therapist, the practice manager and two receptionists.
The practice is owned by a partnership 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. The registered manager at Alpha Dental Studio Dales is the operations manager for the group.
On the day of inspection, we collected 15 CQC comment cards filled in by patients. All comments received were very positive about the care and treatment provided at the practice.
During the inspection we spoke with one orthodontist, one dental nurse, a receptionist, the practice and the registered manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday to Thursday 8.45am to 5.15pm and Friday 8.30am to 4.15pm
Our key findings were:
- The practice appeared clean and well maintained.
- The provider had infection control procedures which reflected published guidance.
- Staff knew how to deal with emergencies.
- The provider had effective systems in place to help them manage risk to patients, with the exception of legionella, where water temperatures were not effectively monitored.
- The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The provider 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.
- Staff provided preventive care and support patients to ensure better oral health.
- The appointment system took account of patients’ needs.
- The provider had effective leadership and culture of continuous improvement.
- Staff felt involved and supported and worked well as a team.
- The provider asked staff and patients for feedback about the services they provided.
- The provider dealt with complaints positively and efficiently.
- The provider had suitable information governance arrangements.
There were areas where the provider could make improvements. They should:
- Take action to implement any recommendations in the practice's Legionella risk assessment, 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, taking action when water temperatures are out of the recommended parameters to ensure a safe water supply.