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Inspection Summary


Overall summary & rating

Updated 22 October 2018

We undertook a focused follow up inspection of Town Moor Dental Care on the 17 September 2018. This inspection was carried out to review in detail the actions taken by the registered provider to improve the quality of care and to confirm that the practice was now meeting legal requirements.

The inspection was led by a CQC inspector who was supported by a specialist dental adviser.

We undertook a comprehensive inspection of Town Moor Dental Care on 29 May 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We found the registered provider was not providing well led care in accordance with the relevant regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can read our report of that inspection by selecting the 'all reports' link for Town Moor Dental Care on our website www.cqc.org.uk.

When one or more of the five questions are not met we require the service to make improvements and send us an action plan. We then inspect again after a reasonable interval, focusing on the area where improvement was required.

As part of this inspection we asked:

• Is it well-led?

Our findings were:

Are services well-led?

We found this practice was providing well-led care in accordance with the relevant regulations.

The provider had made improvements in relation to the regulatory breaches we found at our inspection on 29 May 2018.

Background

Town Moor Dental Care is in Doncaster and provides private treatment to adults and children. Entry into the practice is via a single step. Entry assistance is available if required for people who use wheelchairs and pushchairs. Car parking spaces are available at the practice.

The dental team includes the principal dentist and two dental nurses, one of whom is a trainee. A dentist who specialises in endodontics (root canal treatment) visits the practice monthly. The practice has one treatment room and an instrument decontamination room.

The practice is owned by a company and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers have 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 Town Moor Dental Care Limited was the principal dentist.

During the inspection we spoke with two dental nurses, we spoke with the principal dentist by telephone after the focussed inspection. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday, Wednesday, Thursday and Friday 10am – 7pm

Tuesday 8am – 4pm

Our key findings were:

  • Staff knew how to deal with emergencies. Systems were now in place to monitor emergency medicines and equipment.
  • Improvements had been made to ensure the practice had systems to help them manage risk.
  • Staff knew their responsibilities for safeguarding adults and children, safeguarding policies were now in place and staff were aware of reporting procedures.
  • The practice’s recruitment procedures reflected current legislation.
  • Staff appraisal and induction process were now embedded.
  • Improvements had been made to lead and support the team.
  • Audit processes had improved to ensure continuous improvement and innovation.
Inspection areas

Safe

No action required

Updated 5 July 2018

We found that this practice was providing safe care in accordance with the relevant regulations.

The practice had systems and processes to provide safe care and treatment. Improvements could be made to ensure learning from incidents to help them improve was embedded.

Staff received training in safeguarding and knew how to recognise the signs of abuse. Improvements could be made to ensure staff knew how to report safeguarding concerns.

The practice had a system to record incidents but the process was not fully recorded for learning and improvement.

The recruitment process was not carried out in line with relevant legislation. We saw no evidence of a recruitment policy on the inspection day, this was sent to us after the inspection. Staff files did not contain sufficient evidence to assure us that essential staff checks had been carried out.

Systems in place to manage risk could be improved. The sharps risk assessment did not reflect the process in place at the practice. No risk assessment had been carried out to mitigate the risks associated with manual instrument cleaning.

The system to help them manage emergency medical equipment and medicines was not effective.

Fire safety checks were carried out but there was no documentation in place to support this.

Premises and equipment were clean and properly maintained. The practice followed national guidance for cleaning, sterilising and storing dental instruments.

Effective

No action required

Updated 5 July 2018

We found that this practice was providing effective care in accordance with the relevant regulations.

The dentists assessed patients’ needs and provided care and treatment in line with recognised guidance. Patients described the treatment they received as very good. The dentists discussed treatment with patients so they could give informed consent and recorded this in their records.

The practice had clear arrangements when patients needed to be referred to other dental or health care professionals.

The principal dentist valued the contributions made by the team but a system to support and monitor staff training was not evident.

Caring

No action required

Updated 5 July 2018

We found that this practice was providing caring services in accordance with the relevant regulations.

We received feedback about the practice from four people. Patients were positive about all aspects of the service the practice provided. They told us staff were professional and friendly.

They said that they were given helpful, honest explanations about dental treatment, and said the dentist listened to them.

We saw that staff protected patients’ privacy and were aware of the importance of confidentiality. Patients said staff treated them with dignity and respect.

Responsive

No action required

Updated 5 July 2018

We found that this practice was providing responsive care in accordance with the relevant regulations.

The practice’s appointment system was efficient and met patients’ needs. Patients could get an appointment quickly if in pain.

Staff considered patients’ different needs. This included providing facilities for disabled patients and families with children. The practice had access to telephone and in-house interpreter services and had arrangements to help patients with sight or hearing loss.

The practice took patients views seriously. They valued compliments from patients and responded to concerns and complaints quickly and constructively.

Well-led

No action required

Updated 22 October 2018

We found that this practice was providing well-led care in accordance with the relevant regulations.

The provider had made improvements to the management of the service. This included establishing clear roles and responsibilities for all the practice team. The improvements provided a sound footing for the on-going development of effective governance arrangements at the practice.

Staff were able to demonstrate they were up to date with and aware of policies, procedures and training.

Staff were able to demonstrate they knew how to report safeguarding concerns. Policies had been updated and were now more comprehensive.

Improvements had been made to document and learn from incidents and when monitoring clinical and non-clinical areas of their work. Staff were up to date with the improvements made and were able to demonstrate this.

An effective system was now in place to monitor patient safety alerts; this process was now supported with documentation. We saw confirmation that a retrospective check had been carried out.

We reviewed staff files and found all essential documentation and certification was now in place. Staff induction and appraisal were now embedded and we saw documentation to support this.

Systems in place to manage risk had been improved; risks associated with sharps handling, manual instrument cleaning and fire safety had been assessed. The management of emergency medicines and equipment was now embedded and staff were able to demonstrate this.

Security of the practice had been considered and measures put in place to protect staff and patients.