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Inspection report

Date of Inspection: 10 May 2013
Date of Publication: 15 June 2013
Inspection Report published 15 June 2013 PDF

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 10 May 2013, observed how people were being cared for and talked with people who use the service. We talked with staff.

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 provider had an effective system to assess and monitor the quality of the service that people receive.

The practice had adopted a recognised monitoring scheme to ensure that the service was delivered in a consistant way. The programme checked all aspects of the service including infection control, X ray equipment, patient’s records, patient satisfaction and dental waste. However some of the areas were being monitored on a regular basis; and other areas such as the percentage of grade 3 X rays (poor quality) were only monitored on a “as and when basis” this does not follow published guidelines and professional standards. The provider assured us that regular monitoring of all aspects of the service would be carried out from now on.

We saw evidence of audits. This covered areas such as radiation protection, fire safety, safeguarding, health and safety issues and infection control. This meant that the service provided was monitored to ensure safe and quality care.

We noted that an auditing system was in place to ensure that all emergency drugs had not expired and that equipment, such as oxygen cylinders were effective and in good working order.

The provider may wish to note that the current system for the recording and grading of the diagnostic quality of X ray images did not give any indication of the percentage of grade 3 (poor quality) X rays. It was therefore not possible to determine if poor quality images were within the recommended 10% parameters. Quality control measures for X rays are a mandatory requirement under the Ionising Radiation Regulations 1999 (IRR99).