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Inspection report

Date of Inspection: 7 May 2013
Date of Publication: 31 May 2013
Inspection Report published 31 May 2013 PDF | 82.97 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 7 May 2013, talked with people who use the service and talked with staff. We talked with other regulators or the Department of Health.

Our judgement

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

Reasons for our judgement

People were positive about the quality of the service they received. They felt that staff took account of their needs and wishes when providing treatment.

We saw that the practice had a complaints procedure and a summary of this was displayed in the waiting room. People with whom we spoke told us that they had no concerns or complaints but confirmed they knew how to make a complaint if they were not happy about the service. There was a suggestions box where people could feedback their views and satisfaction surveys were carried out. We looked at the results from the latest survey and saw that people had requested extended opening hours. Following this feedback, we noticed that the practice was now open later, three days a week.

Staff told us and minutes of meetings confirmed that practice meetings were carried out where general issues were discussed. Management meetings for the practice manager and dentists were also held. We looked at the minutes from the last meeting on 17 April 2013; issues such as recruitment and policies and procedures had been discussed. All staff with whom we spoke told us they felt supported by the provider. We concluded that people who used the service and staff were asked for their views about their care and treatment and they were acted on.

We looked at the quality monitoring systems that the provider had in place. We saw there was a range of daily, weekly and monthly checks in place to ensure the quality of the service was monitored closely. These involved daily surgery checks and audits were carried out on infection control, information governance, record keeping and X rays. Tests on the decontamination process and checks that the emergency medicines were in date, were also undertaken. The practice manager told us and records confirmed that “Walkabout inspections” were carried out. These were unannounced inspections which involved the practice manager checking various aspects of the service. We noted that any actions that needed attention were documented with timescales for completion. The provider may find it useful to note that there was no overview or formal monitoring of staff training. Individual staff were in charge of maintaining their own training records. We concluded that there was an effective system in place to regularly assess and monitor the quality of service that people received.