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Inspection report

Date of Inspection: 13 December 2013
Date of Publication: 21 January 2014
Inspection Report published 21 January 2014 PDF | 91.15 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 13 December 2013, talked with people who use the service and talked with staff. We reviewed information given to us by the provider.

Our judgement

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

The dentist had joined a local clinical audit and peer review scheme administered by the NHS commissioning body. This had led them to carry out audits in a regular and accountable way, to check their own practice and assure a safe and reliable service. We saw certificates evidencing clinical audit work over the past five years. These had shown compliance with IPC, child protection, clinical records and radiography.

We saw the results of the six monthly audit carried out by the dentist of the quality of the images her radiographs provided. This showed that the proportion reaching the top quality had not reached the 85% aimed for. However, only 3% were clinically unusable which was within acceptable limits.

We also saw that health and safety risk assessments had been carried out by the dentist as evidence for their continual professional development (CPD). We saw that fire signs had been put up in response to the identification of a shortfall. The lack of an induction programme for new staff was also identified, but there had been no staff recruitment so this still awaited introduction.

The provider may like to note that although the practice policy said that 50 patients per year would be surveyed for their views of the practice, this had not happened. The dentist told us that they carried out a survey of patient satisfaction 18 months previously, but we did not see evidence that they had acted on the findings of patient feedback.

We saw that the dentist and nurse had both undertaken training in complaints management. The code of practice for patient complaints was displayed in the waiting room. The dentist agreed to update the information for people about who they could contact for support if they were not satisfied with the local resolution to a complaint. No written complaints had been received for four years.