31 May 2016
During a routine inspection
We carried out an announced comprehensive inspection on 31 May 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
M & J Dental Surgery is located in the London Borough of Brent and provides mainly NHS dental treatment to both adults and children. The premises are on the ground floor and consist of two treatment rooms, an X-ray room, a reception area and a dedicated decontamination room. The practice is open Monday to Friday 9:00am – 5:00pm.
The staff consists of one principal dentist, two dental nurses, a trainee dental nurse and a receptionist.
The principal dentist is registered with the Care Quality Commission (CQC) as an individual. Like registered providers, they are ‘registered persons’. 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.
We reviewed 42 CQC comment cards and the NHS Friends and Family test comment cards. Patients were positive about the service. They were complimentary about the friendly and caring attitude of the staff.
The inspection took place over one day and was carried out by a CQC inspector and a dental specialist advisor
Our key findings were:
- There were appropriate equipment and access to emergency drugs to enable the practice to respond to medical emergencies. Staff knew where equipment was stored.
- Patients’ needs were assessed and care was planned in line with current guidance such as from the National Institute for Health and Care Excellence (NICE).
- We found the dentists regularly assessed each patient’s gum health and took X-rays at appropriate intervals.
- Patients were involved in their care and treatment planning so they could make informed decisions.
- There were effective processes in place to reduce and minimise the risk and spread of infection.
- The practice had effective safeguarding processes in place and staff understood their responsibilities for safeguarding adults and child protection
- Equipment, such as the autoclave (steriliser), fire extinguishers, and X-ray equipment had all been checked for effectiveness and had been regularly serviced.
- Patients were treated with dignity and respect and confidentiality was maintained.
- The practice had implemented clear procedures for managing comments, concerns or complaints.
- Patients indicated that they found the team to be efficient, professional, caring and reassuring.
- Patients had good access to appointments, including emergency appointments, which were available on the same day
- Leadership structures were clear and there were processes in place for dissemination of information and feedback to staff.
There were areas where the provider could make improvements and should:
- 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).
- Review its 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 training, learning and development needs of individual staff members and have an effective process established for the on-going assessment and supervision of all staff.
- Review its complaint handling procedures and establish an accessible system for identifying, receiving, recording, handling and responding to complaints by patients.
- Review the practice protocols to establish an effective system to assess, monitor and mitigate the various risks arising from undertaking of the regulated activities.
- Review availability of equipment to manage medical emergencies giving due regard to guidelines issued by the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.