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Inspection report

Date of Inspection: 26 September 2013
Date of Publication: 25 October 2013
Inspection Report published 25 October 2013 PDF | 69.26 KB

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 26 September 2013, observed how people were being cared for and talked with staff. We reviewed information given to us by the provider.

Our judgement

The provider had an effective system to regularly assess and monitor the quality of service that people receive. The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

Reasons for our judgement

During our inspection on 6 August 2013 there was no quality assurance process and no audits had been undertaken other than a 2011 audit of X-ray processes and a brief review of decontamination processes. Since this inspection the dentist had implemented a system to regularly assess and monitor the quality of services provided. Immediately following our inspection on 26 September 2013 the dentist sent a completed audit of their decontamination practices using the thorough IPS audit tool recommended by HTM01-05. The dentist had not yet issued patient satisfaction questionnaires but was intending to introduce these shortly. We were told that a plan was being developed to audit key practices, such as when to put on and remove gloves during the stages of the decontamination process. The dentist intended to use audits to note any changes in practice needed and to implement these.

During our inspection on 6 August 2013 we found that systems were not in place to identify hazards and protect staff and patients from them. At our inspection on 26 September 2013 we saw a brief risk assessment had been developed. Immediately following the inspection the dentist sent us an expanded version of this in which each potential hazard had been systematically assessed. Actions the dentist had taken to mitigate these risks were also recorded and we saw, for example, that chemicals were kept in a locked room.

These findings meant that people could be assured that the dentist was minimizing any risks they could face and continuously working to improve his practices and the quality of service offered.