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Chelwood Dental Practice No action required

Inspection Summary


Overall summary & rating

No action required

Updated 30 November 2016

We carried out an announced comprehensive inspection on 5 October 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

Chelwood Dental Practice is situated in Roundhay, which is a district of Leeds, West Yorkshire. It offers mainly NHS dental treatment to patients of all ages. They also provide private treatment including cosmetic dentistry. 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 accessible toilet facilities.

There are three dentists, four dental nurses (one of whom has recently qualified) and one receptionist. One of the dental nurses is also the practice manager.

The opening hours are 8am to 1pm every weekday morning, 2pm to 7pm Monday to Wednesday and 2pm to 5.30pm on Thursdays and Fridays. When the practice is closed, calls are transferred to the NHS 111 service.

The principal dentist 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 25 patients. The patients were positive about the care and treatment they received at the practice. Comments included that staff were friendly and efficient. Several patients commented that the practice was clean. They also commented that they were able to get appointments when they needed them, including same day appointments and staff spent time explaining treatment options.

Our key findings were:

  • The practice had been renovated to a high standard and 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 that 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).
  • We observed that patients were treated with kindness and respect by staff.
  • There was a warm and welcoming feel to the practice.
  • Staff ensured there was sufficient time to explain fully the care and treatment they were providing in a way patients understood.
  • The practice had a complaints system in place and there was an openness and transparency in how these were dealt with.
  • Patients were able to make routine and emergency appointments when needed.
  • The governance systems were effective.
  • There were clearly defined leadership roles within the practice and staff told us that they felt supported, appreciated and comfortable to raise concerns or make suggestions.
  • There was appropriate equipment for staff to undertake their duties, and equipment was well maintained.

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

  • Review stocks of medicines and the system for dispensing and identifying and disposing of out-of-date stock.
  • Review it’s responsibilities as regards to the Control of Substance Hazardous to Health (COSHH) Regulations 2002 and, ensure all documentation is up to date and staff understand how to minimise risks associated with the use of and handling of these substances.
  • Review the practice’s arrangements for receiving and responding to patient safety alerts, recalls and rapid response reports issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and through the Central Alerting System (CAS), as well as from other relevant bodies such as, Public Health England (PHE).
Inspection areas

Safe

No action required

Updated 30 November 2016

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

The provider had effective systems and processes in place to ensure care and treatment were carried out safely, for example, there were systems in place for infection prevention and control, the management of medical emergencies, dental radiography, and investigating and learning from incidents and complaints.

Staff had received training in safeguarding adults and children, knew how to recognise the signs of abuse, and who to report them to.

Staff were appropriately recruited, suitably trained and skilled; there were sufficient numbers of staff. We saw a detailed induction process was in place for new staff. Regular staff appraisals were carried out.

We found the equipment used in the practice, including medical emergency and radiography equipment, was well maintained and tested at regular intervals. The practice had emergency medicines and equipment available, including an automated external defibrillator. Staff were trained in responding to medical emergencies.

The premises was secure and properly maintained. The practice was cleaned regularly and there was a cleaning schedule in place identifying tasks to be completed.

The practice was following current legislation and guidance in relation to X-rays, to protect patients and staff from unnecessary exposure to radiation.

We noted that the COSHH folder was due to be reviewed. This was brought to the attention of the practice manager and registered provider on the day and we were told they would be addressed.

We also saw that the practice did not have a robust system to monitor antibiotics prescribed on a private basis. All antibiotics were in date. This issue was raised on the day and we were told this would be addressed.

Effective

No action required

Updated 30 November 2016

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

The dentists followed current guidelines when delivering dental care and treatment to patients. This included assessing and recording their medical history. Patients received an assessment of their dental health, and treatment provided focused on their individual needs. Patients’ consent was obtained before treatment was provided. Patients were given a written treatment plan which detailed the treatments considered and agreed, together with the fees involved. The practice kept detailed dental records.

The dentists provided oral health advice and guidance to patients and monitored changes in their oral health. Patients were referred to other services, where necessary, in a timely manner.

Qualified staff were registered with their professional body, the General Dental Council, and were supported in meeting the requirements of their professional regulator. Staff received training appropriate to their roles.

Caring

No action required

Updated 30 November 2016

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

Patients commented that staff were caring and friendly. They told us they were treated with respect, and that they were happy with the care and treatment given.

Staff understood the importance of emotional support when delivering care to patients who were nervous of dental treatment. Patient feedback on CQC comment cards confirmed that staff were understanding and made them feel at ease.

The practice had private rooms available if patients wished to speak in private.

Patients were provided with information regarding their treatment and oral health. Patients commented that information given to them was helpful. We found that treatment was clearly explained, and patients were given time to decide before treatment was commenced.

Responsive

No action required

Updated 30 November 2016

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

Patients had access to appointments to suit their preferences, and emergency appointments were available on the same day. Patients could request appointments by telephone or in person. The practice opening hours and the ‘out of hours’ appointment information was provided at the entrance to the practice and in the practice leaflet.

The practice captured social and lifestyle information on the medical history forms completed by patients which helped the dentist to identify patients’ specific needs and direct treatment to ensure the best outcome was achieved for the patient. Staff were prompted to be aware of patients’ specific needs or medical conditions via the use of a flagging system on the dental care records.

The provider had taken into account the needs of different groups of people, for example, people with disabilities, impaired mobility, and wheelchair users. Staff had access to interpreter services where patients required these.

The practice had a complaints policy in place which was displayed in the waiting room. Complaints were thoroughly investigated and responded to appropriately.

Well-led

No action required

Updated 30 November 2016

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

The provider had effective systems and processes in place for monitoring and improving services.

The practice had a management structure in place, and some of the staff had lead roles. Staff were aware of their roles and responsibilities. Staff reported that the provider was approachable and helpful, and took account of their views. The culture of the practice encouraged openness and honesty. Staff told us they were encouraged to raise any issues or concerns.

The provider had put in place a range of policies, procedures and protocols to guide staff in undertaking tasks. We saw that these were regularly reviewed.

The provider used a variety of means to monitor quality and safety at the practice and to ensure continuous improvement, for example, learning from complaints, audits, and patient feedback. We found the dentists and staff had a strong emphasis on learning and continuous improvement. For example, regular attendance at deanery training sessions.

Staff were aware of the importance of confidentiality and understood their roles in this. Dental care records were complete, accurate, and securely stored. Patient information was handled confidentially.

The practice met regularly, and shared information to improve future practice and gave everybody an opportunity to discuss any concerns or issues.