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Inspection Summary


Overall summary & rating

Updated 1 November 2016

We carried out an announced comprehensive inspection on 4 October 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

Hook Road Dental Practice is located in the Royal Borough of Kingston and provides private and NHS dental services. The opening hours for the practice were Monday to Friday 9.00am to 5.00pm

The premises consists of three treatment rooms, a decontamination rooms and waiting area.

The practice comprises of two principal dentists, three dentists, two nurses, a trainee dental nurse and one receptionist.

One of the principal dentists is registered with the Care Quality Commission (CQC) as an individual registered person. 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.

During the inspection we asked patients to complete CQC comment cards. We received 43 comment cards and spoke with three patients on the day of the inspection. The patients who provided feedback were positive about the care and treatment they received at the practice. They told us they were involved in all aspects of their care and found the staff to be caring, friendly and helpful and they were treated with care, dignity and respect.

Our key findings were:

  • There were effective processes in place to reduce and minimise the risk and spread of infection.
  • 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) and Delivering Better Oral Health. Patients were involved in their care and treatment planning.
  • There was appropriate equipment for staff to undertake their duties and equipment was well maintained.
  • Staff were trained in and there was appropriate equipment for them to respond to medical emergencies.
  • Patients told us that staff were caring and treated them with dignity and respect.
  • Patients indicated that they felt they were listened to and that they received good care from a helpful and caring practice team.
  • There were processes in place for patients to give their comments and feedback about the service including making complaints and compliments.
  • There were good governance arrangements and an effective management structure.

There were areas where the provider could make improvements and should

  • Review the current Legionella risk assessment and implement the required actions including the monitoring and recording of water temperatures, taking into account 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 the practice’s audit protocols of various aspects of the service, such as radiography and dental care records at regular intervals to help improve the quality of service. Practice should also check where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.
Inspection areas

Safe

No action required

Updated 1 November 2016

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

There were systems in place to help ensure the safety of staff and patients. These included policies for safeguarding children from abuse, maintaining the required standards of infection prevention and control and maintenance of equipment used at the practice.

The practice assessed risks to patients and managed these well. However at the time of the inspection a Legionella risk assessment had not been carried out. Following the inspection we were provided with evidence that the risk assessment had been booked.

We found that staff were trained and there was some appropriate equipment to respond to medical emergencies. However improvements could be made.

In the event of an incident or accident occurring, the practice had a system in place to document, investigate and learn from it.

The practice followed procedures for the safe recruitment of staff which included carrying out criminal record checks and obtaining references.  

Effective

No action required

Updated 1 November 2016

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

The practice followed guidance, such as that issued by National Institute for Health and Care Excellence (NICE). Patients were given appropriate information to support them to make decisions about the treatment they received. The practice kept detailed dental care records of treatments carried out and monitored any changes in the patient’s’ medical and oral health. Records showed patients were given health promotion advice appropriate to their individual oral health needs such as smoking cessation advice where appropriate.

Staff were supported by the practice in maintaining their continuing professional development (CPD) and were meeting the requirements of their professional registration.

Caring

No action required

Updated 1 November 2016

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

The patient feedback we received was very positive about the service provided by the practice. We observed that staff treated patients with dignity and respect.

We found that dental care records were stored securely, and patient confidentiality was well maintained.

Responsive

No action required

Updated 1 November 2016

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

Patients had good access to routine and emergency appointments at the practice. There was sufficient well maintained equipment to meet the dental needs of their patient population. There was a complaints policy. Patients were given the opportunity to give feedback through the practices own feedback forms. The service was accessible to patients with mobility problems.

Well-led

No action required

Updated 1 November 2016

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

There was a clear vision for the practice that was shared with the staff.  There were good governance arrangements and an effective management structure. Appropriate policies and procedures were in place, and there was effective monitoring of various aspects of care delivery. Audits were under taken; however there was lack of a system to review, analyse and learn from the information collected. Patients were given the opportunity to provide feedback about the practice through the NHS Friends and Family Test.