Woodhall Dental Practice Limited

Updated 3 June 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.

The inspection was carried out on 21 April 2016 by a CQC inspector and two dental specialist advisors. We reviewed information received from the provider prior to the inspection. On the day of our inspection we looked at practice policies and protocols, clinical patient records and other records relating to the management of the service. We spoke with the practice manager (who is also the registered manager), the principal dentist, an associate dentist, a dental nurse and a trainee dental nurse.

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?

This informed our view of the care provided and the management of the practice.

Updated 3 June 2016

We carried out an announced comprehensive inspection on 21 April 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.

Woodhall Dental Practice is a general dental practice in Welwyn Garden City, Hertfordshire offering NHS and private dental treatment to adults and children.

The premises are located all on the ground floor in commercial premises within a parade of shops. The practice consists of three treatment rooms, a reception area and a waiting area. There is also a designated decontamination area in between and access through two of the treatment rooms. There is ample free parking.

The staff at the practice consist of a practice manager, a principal dentist, two associate dentists, a dental nurse and two trainee dental nurses. The practice manager 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:

• There was an induction and training programme for staff to follow which ensured they were skilled and competent in delivering safe and effective care and support to patients.

• The practice ensured staff maintained the necessary skills and competence to support the needs of patients.

• There were effective systems in place to reduce the risk and spread of infection. We found the treatment rooms and equipment were visibly clean.

• There were systems in place to check equipment had been serviced regularly, including the dental air compressor, autoclaves, fire extinguishers, oxygen cylinder and the X-ray equipment.

• We found the dentists regularly assessed each patient’s gum health and took X-rays at appropriate intervals.

• The practice kept up to date with current guidelines when considering the care and treatment needs of patients.

• Staff had been trained to handle emergencies and appropriate medicines and life-saving equipment were readily available.

• Patients received clear explanations about their proposed treatment, its costs, benefits and risks and were involved in making decisions about it.

• Patients were treated with dignity and respect and confidentiality was maintained.

• The appointment system met the needs of patients.

• There was an effective complaints system and the practice was open and transparent with patients if a mistake had been made.

• Staff demonstrated knowledge of the practice whistleblowing policy and were confident they would raise a concern about another staff member’s performance if it was necessary.

• At our visit we observed staff were caring and professional.

• We received feedback from 33 patients who reported they received a high standard of care from friendly staff in a clean and relaxing environment.

• There was an effective system in place to act on feedback received from patients and staff.

• There were systems in place to assess, monitor and improve the quality of service provided.

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

• Review the process for maintaining dental care records giving due regard to guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.

• Review audit protocols to ensure learning points are shared with all relevant staff and that the resulting improvements can be demonstrated as part of the audit process. For example, with regard to their radiography and record keeping audits.

• Review the current legionella risk assessment and implement the required actions including the monitoring and recording of water temperatures, giving due regard to the guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.

• 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 practice’s protocols for recording in the patients’ dental care records or elsewhere the reason for taking the X-ray and quality of the X-ray giving due regard to the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2000.

• Review the protocol for maintaining accurate, complete and detailed records relating to employment of staff. This includes making appropriate notes of verbal references taken and ensuring recruitment checks, including references, are suitably obtained and recorded.

• Review the availability of hand towel dispensers next to each hand wash sink and ensure the ‘clean’ and ‘dirty’ zones are clearly demarcated in each treatment room.