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Inspection Summary


Overall summary & rating

Updated 15 April 2019

We carried out this announced inspection on 12 March 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

Bupa Dental Care Dereham is a well-established practice which provides both NHS and private treatment to approximately 8,000 patients. The dental team includes five dentists, one hygienist, eight nurses, three receptionists and a practice manager. The practice has five treatment rooms.

The practice opens on Mondays, Tuesdays and Thursdays from 8am to 7pm; on Wednesday from 8am to 6pm, and on Fridays from 8.15 to 5pm. The practice is also open one Saturday a month for hygienist appointments.

The practice has limited parking facilities, primarily for patients with disabilities, but there is car parking nearby. Wheelchair access is available and there are three ground floor treatment rooms.

The practice is owned by a 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. The registered manager at the practice is the practice manager.

On the day of inspection, we collected 47 CQC comment cards filled in by patients and spoke with two other patients. We spoke with two dentists, three dental nurses, reception staff and the practice manager. One of the provider’s area compliance leads was also on site. We looked at practice policies and procedures and other records about how the service is managed.

Our key findings were:

  • Infection control procedures reflected published guidance.
  • Staff knew how to deal with emergencies, and appropriate medicines and life-saving equipment were available.
  • The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • The practice had thorough staff recruitment procedures.
  • Patients’ care and treatment was provided in line with current guidelines.
  • The practice offered evening and Saturday morning appointments.
  • The practice took complaints and concerns seriously and responded to them appropriately to improve the quality of care.
  • The practice had effective leadership and culture of continuous improvement.

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

  • Review the practice’s sharps procedures and ensure the practice follows the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

  • 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.
Inspection areas

Safe

No action required

Updated 15 April 2019

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

The practice had robust arrangements for essential areas such as clinical waste, the management of medical emergencies, infection control and dental radiography (X-rays).

Staff had received safeguarding training and were aware of their responsibilities regarding the protection of children and vulnerable adults. There were sufficient numbers of suitably qualified staff working at the practice and staff were qualified for their roles.

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

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

Effective

No action required

Updated 15 April 2019

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

Patients told us they were very happy with the quality of their treatment. Staff had the skills, knowledge and experience to deliver effective care and treatment. The dental care provided was evidence based and focussed on the needs of the patients. The practice used current national professional guidance including that from the National Institute for Health and Care Excellence (NICE) to guide their practice. The staff received professional training and development appropriate to their roles and learning needs.

The promotion of oral health was given high priority within the practice.

The practice had clear arrangements when patients needed to be referred to other dental or health care professionals, and referrals were monitored to ensure they had been received.

Caring

No action required

Updated 15 April 2019

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

Patients were positive about all aspects of the service the practice provided and spoke highly of the treatment they received, and of the staff who delivered it. Patients said staff treated them in a way that they liked.

Staff gave us specific examples of where they had gone out of their way to support patients.

We saw that staff protected patients’ privacy and were aware of the importance of handling information about them confidentially.

Responsive

No action required

Updated 15 April 2019

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

The practice’s appointment system was efficient and met patients’ needs. Patients could get an appointment quickly if in pain. Patients could book appointments in the early evening and on Saturdays. The practice offered patients an email and text appointment reminder service.

Staff considered patients’ different needs. This included providing facilities for disabled patients, and families with children. The practice had access to interpreter services and had arrangements to help patients with sight or hearing loss.

The practice took patients’ views seriously. Staff valued compliments from patients and responded to concerns and complaints quickly and effectively.

Well-led

No action required

Updated 15 April 2019

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

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. 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.