Kelvin Lodge Dental Practice

Updated 19 December 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 registered provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The inspection took place on 04 November 2016. It was led by a CQC inspector and supported by a dental specialist advisor.

During the inspection, we spoke with the practice manager, three dentists, a dental nurse, a dental hygienist and the sterilisation assistant.

We reviewed policies, protocols, certificates and other documents to consolidate our findings.

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 therefore formed the framework for the areas we looked at during the inspection.

Updated 19 December 2016

We carried out an announced comprehensive inspection on 04 November 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

Kelvin Lodge dental practice was established in 2016 as part of the BUPA group of dental practices. Situated in a residential area in Gosforth, Tyne and Wear, the practice provides predominantly private treatment to patients of all ages.

The practice is housed in a three storey building with eight treatment rooms spread over two floors, two waiting rooms and two interconnecting decontamination rooms for sterilising dental instruments. The basement includes a staff room, kitchen and three storage rooms. Ample car parking is available within the practice grounds. Access for wheelchair users or pushchairs is possible via the ramp outside.

The practice is open Monday – Friday 0830-1730.

The dental team is comprised of the practice manager, six dentists, four hygienists, a dental therapist, eight dental nurses, a sterilisation assistant and five receptionists.

The practice manager is the registered manager. A registered manager is a person who is registered with the Care Quality Commission (CQC) 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.

We reviewed 46 CQC comment cards on the day of our visit; patients were very positive about the staff and standard of care provided by the practice. Patients commented they felt involved in all aspects of their care and found the staff to be helpful, respectful, friendly and were treated in a clean and tidy environment.

Our key findings were:

• The practice was well organised, visibly clean and free from clutter.
• Staff were very friendly, caring and enthusiastic.
• An Infection prevention and control policy was in place. We saw the sterilisation procedures followed recommended guidance.
• Staff received annual medical emergency training.
• Equipment for dealing with medical emergencies reflected guidance from the resuscitation council.
• The practice had systems for recording incidents and accidents.
• Practice meetings were used for shared learning.
• Dental professionals provided treatment in accordance with current professional guidelines.
• Patient feedback was regularly sought and reflected upon.
• Complaints were dealt with in an efficient and positive manner.
• Patients could access urgent care when required.
• Dental professionals were maintaining their continued professional development (CPD) in accordance with their professional registration.
• Staff were aware on how to escalate safeguarding issues for children and adults should the need arise

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

• Review the need for hygienists to be suitably supported by a trained member of the dental team when treating patients in a dental setting.
• Review the need to carry out a risk assessment where a dental hygienist is to work alone.

• 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.