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Bupa - Kenworthy Street, Stalybridge

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Inspection Summary


Overall summary & rating

Updated 16 October 2018

We carried out this announced inspection on 24 September 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.

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

Bupa – Kenworthy Street, Stalybridge is in Greater Manchester and provides mostly NHS and some private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking is available near the practice.

The dental team includes five dentists, six dental nurses (one of whom is a trainee and one dental nurse also covers reception duties), a dedicated receptionist and a dental hygienist. The team also includes a practice manager and a practice co-ordinator. The company clinical support lead was also present during the inspection. The practice has five treatment rooms.

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 Bupa – Kenworthy Street, Stalybridge is the practice manager.

On the day of inspection we collected 13 CQC comment cards filled in by patients.

During the inspection we spoke with three dentists, the practice manager and company clinical support lead. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Friday 8am to 6pm

Our key findings were:

  • The practice appeared clean and well maintained.
  • The provider had infection control procedures which reflected published guidance.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
  • The practice had systems to help them manage risk to patients and staff.
  • The practice staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • The provider had thorough staff recruitment procedures.
  • The clinical staff provided patients’ care and treatment in line with current guidelines.
  • Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • The provider was providing preventive care and supporting patients to ensure better oral health.
  • The appointment system met patients’ needs.
  • The practice had effective leadership and culture of continuous improvement.
  • Staff felt involved and supported and worked well as a team.
  • The practice asked staff and patients for feedback about the services they provided.
  • The provider dealt with complaints positively and efficiently.
  • The provider had suitable information governance arrangements.

There were areas where the provider could make improvements. They should:

  • Review the practice’s protocols for recording in the patients’ dental care records or elsewhere the reason for taking X-rays, a report on the findings and the quality of the image in compliance with Ionising Radiation (Medical Exposure) Regulations 2017. In addition, review current X-ray audit processes to ensure documented learning points and resulting improvements can be demonstrated.
  • Review the practice’s protocols in respect to an awareness of national oral health campaigns and local schemes available in supporting patients to live healthier lives.
Inspection areas

Safe

No action required

Updated 16 October 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. They used learning from incidents and complaints to help them improve.

Staff received training in safeguarding people and knew how to recognise the signs of abuse and how to report concerns.

Staff were qualified for their roles and the practice completed essential recruitment checks.

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

The practice had suitable arrangements for dealing with medical and other emergencies.

Improvements could be made to ensure all dentists justified, graded and reported on the radiographs they took and that X-ray audit scores were recorded to check for improvements and learning.

The dentist were not aware of national oral health campaigns and local schemes available in supporting patients to live healthier lives. For example, local stop smoking services. We were assured measures would be taken to improve this.

Effective

No action required

Updated 16 October 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 fabulous, very good and exceptional. 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 practice supported staff to complete training relevant to their roles and had systems to help them monitor this.

Caring

No action required

Updated 16 October 2018

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

We received feedback about the practice from 13 people. Patients were positive about all aspects of the service the practice provided. They told us staff were caring, accommodating and professional.

They said that they were given helpful, honest explanations about dental treatment, and said their dentist listened to them. Patients commented that they made them feel at ease, especially when they were anxious about visiting the dentist, they would recommend this practice to everyone and stated the team always go one step further to provide the best treatment.

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 16 October 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 face to face 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 16 October 2018

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

The practice had arrangements to ensure the smooth running of the service. These included systems for the practice team to discuss the quality and safety of the care and treatment provided. There was a clearly defined management structure and staff felt supported and appreciated.

The practice team kept complete patient dental care records which were, clearly written or typed and stored securely.

The practice monitored clinical and non-clinical areas of their work to help them improve and learn. This included asking for and listening to the views of patients and staff.