You are here

Inspection Summary


Overall summary & rating

Updated 14 August 2018

We carried out this announced inspection on 19 July 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

Serenity Dental Surgery is in Burnham On Crouch and provides 90% NHS and 10% private treatment to adults and children.

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

The dental team includes three dentists, two dental nurses, two dental hygienists, two receptionists and a visiting implant surgeon. The practice has two treatment rooms.

The practice is owned by a partnership 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 Serenity Dental Surgery was the principal dentist.

On the day of inspection, we collected 11 CQC comment cards filled in by patients and spoke with two other patients.

During the inspection we spoke with two dentists, two dental nurses and one receptionist. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open: Monday to Friday from 8.45am to 5pm.

Our key findings were:

  • The practice appeared clean and well maintained.
  • The practice staff had infection control procedures which reflected published guidance.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available with the exception of some airways and a paediatric ambubag. We found that some needles and syringes were out of date. The practice did not carry the correct form of medicine to manage diabetic seizures and there was no 300mg aspirin available. Following the inspection, the practice confirmed these were immediately ordered.
  • The practice had systems to help them manage risk.
  • The practice staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
  • The practice 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. Feedback from patients was wholly positive.
  • The practice 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 practice staff dealt with complaints positively and efficiently.
  • The practice staff had suitable information governance arrangements.

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

  • Review the practice's Legionella risk assessment and implement any recommended actions, taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.’ In particular with regard to ensuring a Legionella risk assessment is undertaken by a qualified and competent provider.
Inspection areas

Safe

No action required

Updated 14 August 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 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. There were no records of fixed wire electrical testing retained at the practice. The practice followed national guidance for cleaning, sterilising and storing dental instruments. A Legionella risk assessment had been undertaken, but there was no evidence to confirm this was undertaken by a qualified and competent provider. Following the inspection the provider sent confirmation that fixed wire testing and a Legionella risk assessment had been scheduled.

Appropriate medicines and life-saving equipment were available with the exception of some airways and a paediatric ambubag. We found that some needles and syringes were out of date. The practice did not carry the correct form of medicine to manage diabetic seizures and there was no 300mg aspirin available. Following the inspection, the practice confirmed these were immediately ordered.

Effective

No action required

Updated 14 August 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 efficient, professional and caring. 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 14 August 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 excellent, kind and helpful.

They said that they were given detailed and 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.

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 14 August 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 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 14 August 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.