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Inspection Summary


Overall summary & rating

Updated 21 December 2016

We carried out an announced comprehensive inspection on 17 November 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

Courtyard Dental Care is situated in Pontefract, West Yorkshire. The practice offers predominately NHS dental treatments to patients of all ages. The services include preventative advice and treatment and routine restorative dental care.

The practice has two surgeries, a decontamination room, a waiting area and a reception area. All of the facilities are on the ground floor of the premises along with toilets.

There are two dentists and four dental nurses (one of whom is a trainee and one also covers the duties of a practice manager).

The opening hours are Monday to Friday from 9-00am to 5-00pm.

The practice owner is registered with the Care Quality Commission (CQC) as an individual. 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.

During the inspection we received feedback from 29 patients. The patients were positive about the care and treatment they received at the practice. Comments included staff were friendly, caring and respectful. They also commented the premises were clean and hygienic and they could get emergency appointments when required.

Our key findings were:

  • The practice was visibly clean and uncluttered.
  • The practice had systems in place to assess and manage risks to patients and staff including health and safety and the management of medical emergencies.
  • Staff were qualified and had received training appropriate to their roles.
  • Patients were involved in making decisions about their treatment and were given clear explanations about their proposed treatment including costs, benefits and risks.
  • Dental care records showed treatment was planned in line with current best practice guidelines.
  • Oral health advice and treatment were provided in-line with the ‘Delivering Better Oral Health’ toolkit (DBOH).
  • Staff ensured there was sufficient time to explain fully the care and treatment they were providing in a way patients understood.
  • Patients were able to make routine and emergency appointments when needed.
  • The governance systems were effective.
  • Staff told us they felt supported, appreciated and comfortable to raise concerns or make suggestions.
  • The practice had a complaints system in place. The complaints procedure in the waiting room was not up to date and there was no system in place to record verbal complaints.
  • We observed some breaches of confidentiality in the waiting area.

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

  • Review the practice’s safeguarding policy ensuring the contact details of the local safeguarding team are readily available.
  • Review its responsibilities as regards to the Control of Substance Hazardous to Health (COSHH) Regulations 2002 and, ensure all substances are risk assessed and staff understand how to minimise risks associated with the use of and handling of these substances.
  • Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.
  • Review staff’s awareness of confidentiality to ensure no personal details are discussed at the reception desk.
  • Review the practice’s process to ensure the Infection Prevention Society (IPS) audits are completed on a six monthly basis.
  • Review its complaint handling procedures and establish an accessible system for identifying, receiving, recording, handling and responding to complaints by patients.
Inspection areas

Safe

No action required

Updated 21 December 2016

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

Staff told us they felt confident about reporting incidents, accidents and the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR).

Staff had received training in safeguarding at the appropriate level and knew the signs of abuse and who to report them to. The contacts for the local safeguarding team were not readily available.

Staff were suitably qualified for their roles and the practice had undertaken the relevant recruitment checks to ensure patient safety.

Patients’ medical histories were obtained before any treatment took place. The dentists were aware of any health or medication issues which could affect the planning of treatment. Staff were trained to deal with medical emergencies. All emergency equipment and medicines were in date and in accordance with the British National Formulary (BNF) and Resuscitation Council UK guidelines.

The decontamination procedures were effective and the equipment involved in the decontamination process was regularly serviced, validated and checked to ensure it was safe to use. We noted the Infection Prevention Society (IPS) audit had not been completed every six months.

Effective

No action required

Updated 21 December 2016

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

Patients’ dental care records provided comprehensive information about their current dental needs and past treatment. The practice monitored any changes to the patient’s oral health and provided treatment when appropriate.

The practice followed best practice guidelines when delivering dental care. These included Faculty of General Dental Practice (FGDP), National Institute for Health and Care Excellence (NICE) and guidance from the British Society of Periodontology (BSP).

The practice provided preventative advice and treatment in line with the ‘Delivering Better Oral Health’ toolkit (DBOH). This included fluoride application, oral hygiene advice and smoking cessation advice.

Staff had completed training relevant to their roles and were up to date with their continuing professional development (CPD).

Referrals were made to secondary care services if the treatment required was not provided by the practice.

Not all staff had a good awareness of the requirements of the Mental Capacity Act (MCA) 2005.

Caring

No action required

Updated 21 December 2016

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

During the inspection we received feedback from 29 patients. Patients commented staff were friendly, caring and respectful.

We observed the staff to be welcoming and caring towards the patients.

We observed privacy and confidentiality were not always maintained during interactions at the reception desk. For example, medical histories were checked at the reception desk.

Responsive

No action required

Updated 21 December 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. There were vacant appointments slots for urgent or emergency appointments each day. Patients confirmed they could get emergency appointments. There were clear instructions for patients requiring urgent care when the practice was closed.

There was a procedure in place for responding to patients’ complaints. This involved acknowledging, investigating and responding to individual complaints or concerns. The practice did not record verbal complaints. The complaints procedure in the waiting area was not up to date.

Well-led

No action required

Updated 21 December 2016

We found that this practice was providing well-led care in accordance with the relevant regulations.

There was a range of policies, procedures and protocols to guide staff in undertaking tasks.

Effective arrangements were in place to share information with staff by means of practice meetings. This gave everybody an opportunity to openly share information and discuss any concerns or issues.

The practice regularly audited X-rays and dental care records as part of a system of continuous improvement and learning.

They conducted patient satisfaction surveys and the NHS Friends and Family Test (FFT).