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Archived: Robinspool Dental Practice

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Inspection report

Date of Inspection: 22 August 2014
Date of Publication: 2 October 2014
Inspection Report published 02 October 2014 PDF | 68.13 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 22 August 2014, talked with staff and reviewed information sent to us by other regulators or the Department of Health. We were accompanied by a specialist advisor.

Our judgement

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of patients who used the service and others.

Reasons for our judgement

When we visited the practice on 28 February 2014, we found the practice did not have effective systems in place to identify, assess and manage risks to the health, safety and welfare of patients who used the service and others. The practice did not use audits to inform and improve patient care. Systems were not in place to regularly review and update policies and procedures. The complaints procedure was not easily accessible. The practice did not have systems in place to ensure they learnt from complaints and from incidents and accidents. We set a compliance action in respect of this. We received an action plan which set out what actions were to be taken, to achieve compliance.

During this inspection we found the practice had taken effective action and achieved compliance.

We reviewed a number of policies and procedures, which included the infection control and complaints procedures. The policies were dated and a review date was recorded. We saw all staff members had signed to confirm they had read and understood the procedures. We found the procedures were in date and reflected current professional guidance. The practice had designated a staff member to review all practice protocols on a regular basis and any changes were shared with the team.

We saw the complaints procedure had been displayed in the waiting room. We noted the procedure provided information on how to make a complaint, the person responsible for handling the complaint and the how it would be dealt with. Staff told us a complaints leaflet was also available for patients to take with them, should they wish to.

One of the dentists was responsible for ensuring any relevant professional standards and guidance was shared with the team. This was supported by the staff we spoke with. The practice had discussed all complaints, accidents and incidents and learning was shared with the team. Staff told us although formal team meetings did not take place, the team met frequently on an informal basis where information and training was shared.

We saw evidence the practice had completed various audits and used the findings to improve the quality of the service provided to patients. These included; infection control audits, radiography audits and patient feedback form audit. For example, we reviewed an infection control audit dated April 2014, and saw this had identified the practice did not always date the sharps containers in line with or in accordance with the practice procedures. We saw evidence this had been actioned and the learning had been shared with staff. We saw all audits had a review date recorded, to ensure these took place regularly.