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Inspection Summary


Overall summary & rating

Updated 20 August 2018

We carried out this announced inspection on 19 July 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 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

Marjory Lees Dental Centre is in Oldham and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. The practice has a car park, which includes spaces for blue badge holders.

The dental team includes six dentists (three partners and three associate dentists), nine dental nurses, and two receptionists. The practice has six treatment rooms.

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 Marjory Lees Dental Centre was the senior partner.

On the day of inspection, we collected 44 CQC comment cards filled in by patients, with a further seven completed by staff and one completed by a service engineer.

During the inspection we spoke with four dentists, four dental nurses and a receptionist. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Thursday 8.30am to 12.30pm and 1.30pm to 5pm

Friday 8.30am to 12.30pm

Our key findings were:

  • The practice appeared clean and well maintained.
  • The practice staff had infection control procedures which reflected published guidance.
  • Staff knew how to deal with emergencies. Minor improvements were needed to the life-saving equipment available.
  • The practice had systems to help them identify and manage risk.
  • The practice staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
  • The practice 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.
  • 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 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.
  • The practice staff had suitable information governance arrangements.

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

  • Review the practice’s system for recording, investigating and reviewing incidents or significant events with a view to documenting decisions, preventing further occurrences and ensuring that improvements are made as a result.
Inspection areas

Safe

No action required

Updated 20 August 2018

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

The practice had systems and processes to provide safe care and treatment. They used learning from incidents and complaints to help them improve. We highlighted that the documentation of decisions not to follow up incidents could be improved.

Staff received training in safeguarding and knew how to recognise the signs of abuse and how to report concerns.

Staff were qualified for their roles and the practice completed essential recruitment checks.

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

The practice had suitable arrangements for dealing with medical and other emergencies. Immediate action was taken to replace missing and expired medical oxygen masks.

Effective

No action required

Updated 20 August 2018

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

The dentists assessed patients’ needs and provided care and treatment in line with recognised guidance. Patients described how the staff created a relaxing environment and put them at ease when they received treatment. The dentists discussed treatment with patients so they could give informed consent and recorded this in their records.

The practice had clear arrangements when patients needed to be referred to other dental or health care professionals.

The practice supported staff to complete training relevant to their roles and had systems to help them monitor this.

Dental nurses with additional skills provided oral hygiene and fluoride varnish clinics as prescribed by a dentist, particularly during busy school holiday periods.

The staff were involved in quality improvement initiatives such as good practice certification scheme and peer review as part of its approach in providing high quality care.

Caring

No action required

Updated 20 August 2018

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

We received feedback about the practice from 44 patients. Patients were positive about all aspects of the service the practice provided. They told us staff were professional, caring and attentive. They said that they were given helpful, honest explanations about dental treatment, and said their dentist listened to them. Patients commented that they made them feel at ease, especially when they were anxious about visiting the dentist.

We saw that staff protected patients’ privacy and were aware of the importance of confidentiality. Patients said staff treated them with dignity and respect.

Responsive

No action required

Updated 20 August 2018

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.

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. They valued compliments from patients and responded to concerns and complaints quickly and constructively.

Well-led

No action required

Updated 20 August 2018

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

The practice had a culture of high-quality sustainable care. On the day of the inspection, all staff valued the opportunity to engage in discussion and feedback to improve the practice. Teamwork was evident.

The practice had arrangements to ensure the smooth running of the service. These included systems for the practice team to discuss the quality and safety of the care and treatment provided. There was a clearly defined management structure and staff felt supported and appreciated.

The practice held regular structured staff meetings. We saw how these were used to provide in-house training and encourage staff to participate in discussion to improve procedures and services for patients.

The practice team kept complete patient dental care records which were clearly written or typed and stored securely.

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.