23 May 2019
During a routine inspection
We carried out this announced inspection on 23 May 2019 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a CQC inspector who was supported by a specialist dental adviser.
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 form the framework for the areas we look at during the inspection.
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
Heywood Dental Practice is in Lancashire and provides NHS and private treatment to adults and children.
There is level access for people who use wheelchairs and those with pushchairs. On street parking is available near the practice.
The dental team includes the principal dentist, a foundation dentist and four dental nurses who also have administrative duties. One of the dental nurses has a managerial role and one is a trainee. The practice has two treatment rooms.
The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.
On the day of inspection, we collected 36 CQC comment cards filled in by patients.
During the inspection we spoke with the principal dentist, the foundation dentist, two dental nurses and the dental nurse in a managerial role. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday 9am to 1pm and 2pm to 5pm
Tuesday 1:15pm to 7pm
Wednesday 9am to 1pm and 2:00 to 4:30
Thursday 9am to 1pm and 2pm to 5pm
Friday 8am to 12:30pm and 1:30pm to 3:30pm
Our key findings were:
- The premises were clean and well maintained.
- The provider had infection control procedures which reflected published guidance.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- The practice had systems to help them identify and manage risk to patients and staff. There were some areas that could be improved.
- The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The provider had thorough staff recruitment procedures.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
- Staff were providing preventive care and supporting patients to ensure better oral health.
- The appointment system took account of patients’ needs.
- The provider had effective leadership and culture of continuous improvement.
- Staff felt involved and supported and worked well as a team.
- The provider asked staff and patients for feedback about the services they provided.
- The provider dealt with complaints positively and efficiently.
- The provider had suitable information governance arrangements.
There were areas where the provider could make improvements. They should:
- Review the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment.
- Review the practice's policy for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken.
- Review the security of NHS prescription pads in the practice and the systems to track and monitor their use.
- Review the practice’s protocols for ensuring that all clinical staff have adequate immunity for vaccine preventable infectious diseases.