We carried out an announced comprehensive inspection on 9 June 2015 to ask the practice the following key questions; Are services safe, effective, caring, responsive and well-led?
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 services in accordance with the relevant regulations
Are services well-led?
We found that this practice was not providing well-led care in accordance with the relevant regulations
We carried out an announced comprehensive inspection on 9 June 2015.
The premises consists of a waiting area on the ground floor, a reception area, an accessible treatment room on the ground floor and three treatment rooms on the first floor. There is also a separate decontamination room.
The staff at the practice consists of the principal dentist, two associate dentists, a practice manager (who was on leave on the day of our inspection), two reception staff and three dental nurses. The practice has the services of a dental hygienist who carries out preventative advice and treatment on prescription from the dentists.
The principal dentist (the provider) is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is run.
We spoke with five patients on the day of our inspection. Feedback received from patients was positive in all aspects of the care provided.
Our key findings were:
- Staff were aware of the safeguarding processes to follow to raise any concerns in the practice.
- There were sufficient numbers of suitably qualified staff to meet the needs of patients.
- Staff had been trained to handle emergencies and appropriate medicines and life-saving equipment were readily available.
- Infection control procedures were in place and the practice followed published guidance.
- There was evidence that patient’s care and treatment was not planned and delivered in line with evidence based guidelines, best practice and current legislation.
- Documented evidence was not always evident to show patients received clear explanations about their proposed treatment, costs, benefits and risks and were involved in making decisions about it.
- Patients were treated with dignity and respect and confidentiality was maintained.
- The appointment system met the needs of patients and waiting times were kept to a minimum.
- There was an effective complaints system.
- Governance systems were not effective and there was not a range of clinical and non-clinical audits to monitor and improve the quality of services.
We identified regulations that were not being met and the provider must:
- Assess, monitor and improve the quality of the services provided through audits and other checks including following practice recruitment policy.
- Maintain an accurate and complete record in respect of each patient, including a record of the care and treatment provided to the patient.
You can see full details of the regulations not being met at the end of this report.
There were areas where the provider could make improvements and should:
- Ensure all risks associated with COSHH are approapriately identified and managed.
- Ensure any relevant patient safety alerts are followed up.
- Review the practice’s protocols and procedures for promoting the maintenance of good oral health giving due regard to guidelines issued by the Department of Health publication ‘Delivering Better Oral Health: an evidence-based toolkit for prevention’.
- Ensure all staff familiarise themselves with operating emergency equipment.
- Ensure staff are aware of all policies and procedures that are in place.
- Ensure minutes of meetings are detailed.
- Review the practice’s protocols for the use of rubber dam for root canal treatment giving due regard to guidelines issued by the British Endodontic Society