Updated 10 April 2018
We carried out this announced inspection on 22 February 2018 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.
We told the NHS England Cheshire and Merseyside area team that we were inspecting the practice. We did not receive any information of concern from them.
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
Queens Drive is located in a residential suburb of Liverpool and provides dental care and treatment to adults and children on an NHS and privately funded basis. The practice also accepts orthodontic and oral surgery referrals.
The provider has installed a ramp to facilitate access to the practice for wheelchair users and for pushchairs. The practice has three treatment rooms. Car parking is available near the practice.
The dental team includes five dentists, two dental hygiene therapists, an orthodontic therapist, five dental nurses, three of whom are trainees, and a receptionist. The team is supported by a practice manager.
The practice is owned by a company and as a condition of registration must have in place a person registered with the Care Quality Commission as the registered manager. Registered managers have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run. The registered manager at Queens Drive is the principal dentist.
We received feedback from 24 people during the inspection about the services provided. The feedback provided was positive about the practice.
During the inspection we spoke to two dentists, dental nurses, the receptionist and the practice manager. We looked at practice policies, procedures and other records about how the service is managed.
The practice is open:
Monday to Friday 9.00am to 5.00pm
Saturday by appointment.
Our key findings were:
- The practice was clean and well maintained.
- The practice had infection control procedures in place which reflected published guidance.
- Staff knew how to deal with emergencies. Appropriate medical emergency medicines and equipment were available.
- The practice had safeguarding processes in place and staff knew their responsibilities for safeguarding adults and children.
- Staff provided patients’ care and treatment in line with current guidelines.
- The practice had a procedure in place for dealing with complaints.
- Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
- The appointment system took patients’ needs into account. Dedicated emergency appointments were available.
- The practice had a leadership structure. Staff felt involved and supported and worked well as a team.
- The practice asked patients and staff for feedback about the services they provided.
- The practice had systems in place to help them manage risk. Risks to the health of some staff had not been fully assessed and mitigated.
- The practice had staff recruitment procedures in place. They were not always following these.
There were areas where the provider could make improvements and should:
- Review the practice’s system for assessing, monitoring and mitigating the various risks arising from the undertaking of the regulated activities, specifically in relation to staff vaccination requirements.
- Review the storage of paper-based dental care records to ensure they are stored securely.
- Review the protocol for maintaining accurate, complete and detailed records relating to the employment of staff. This includes ensuring recruitment checks are carried out and suitably recorded.
- Review the practice’s protocols in relation to the use of closed circuit television to ensure staff and patients are fully informed as to its purpose and their right to access footage.