Archived: Ashurst Dental Surgery

Updated 26 July 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

Further to the outcome of a previous inspection, carried out in May 2015, we carried out an announced focused inspection relating to the to the clinical governance systems of the location on 17 June 2016. The inspection was led by a CQC inspector.

During the inspection, we spoke with the practice administrator and reviewed policies, procedures and other documents.

To get to the heart of patients’ experiences of care and treatment, we always asked the following question:

• Is it well-led?

This question formed the framework for the areas we looked at during this inspection.

Updated 26 July 2016

Further to the outcome of a previous inspection, carried out in May 2015, we carried out an announced focused inspection relating to the clinical governance systems of the location on 17 June 2016 to ask the practice the following key question;

Are services well-led in relation to provision of dental care?

Our findings were:

Are services well-led?

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

Background

Ashurst Dental Surgery offers mainly (more than 80%) NHS dental care services to patients of all ages. Approximately 40% of patients attending the practice do not speak English as their first language. Staff spoke a number of languages including Polish, Lithuanian and Russian which supported patients to communicate their needs. The services provided include preventative advice and treatment and routine and restorative dental care. The practice has a treatment room on the ground and one on the first floor of the premises.

The practice has two dentists, one of whom is the principal dentist; a dental nurse, a trainee dental nurse and a receptionist/administrator. The principal dentist is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. 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.

Our key findings were:

All of the requirements set out by the Care Quality Commission in relation to governance at the previous practice inspection had been met:

• An incident reporting policy and system of reporting incidents had been developed and introduced.
• A team based training event for dealing with medical emergencies had been undertaken at the practice.
• A comprehensive health and safety risk assessment had been carried out by the practice to mitigate the risks to patients, staff and visitors.
• A control of substances hazardous to health (COSHH) policy had been introduced to underpin the data sheets in the COSHH file.
• A new system had been put in place to meet the requirements of the Ionising Radiation Regulations 1999.
• Improvements had been made to clinical record keeping.
• The practice had introduced a comprehensive system for capturing and evaluating patient feedback.
• The practice had reviewed their systems for clinical audit and had introduced a rolling programme of audit topics.
• The practice had introduced a system for recording the training that had been undertaken by all members of staff.