• Dentist
  • Dentist

Archived: Hillcrest Dental Surgery

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142 Penn Road, Wolverhampton, West Midlands, WV3 0DZ (01902) 341991

Provided and run by:
Dr Vian Ansari

Important: The provider of this service changed. See new profile
Important: The provider of this service changed. See old profile

All Inspections

6 June 2018

During an inspection looking at part of the service

We carried out a focused inspection of Hillcrest Dental Surgery on 6 June 2018.

The inspection was led by a CQC inspector who was supported by a specialist dental adviser.

We carried out the inspection to follow up concerns we originally identified during a comprehensive inspection at this practice on 7 November 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions.

At a comprehensive inspection we always ask the following five questions to get to the heart of patients’ experiences of care and treatment:

  • Is it safe?
  • Is it effective?
  • Is it caring?
  • Is it responsive to people’s needs?
  • Is it well-led?

When one or more of the five questions is not met we require the service to make improvements and send us an action plan. We then inspect again after a reasonable interval, focusing on the area(s) where improvement was required.

At the previous comprehensive inspection, we found the registered provider was providing safe, effective, caring and responsive care in accordance with relevant regulations. We judged the practice was not providing well-led care in accordance with regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can read our report of that inspection by selecting the 'all reports' link for Hillcrest Dental Surgery on our website www.cqc.org.uk.

Our findings were:

Are services well-led?

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

The provider had made improvements to put right the shortfalls and deal with the regulatory breach we found at our inspection on 7 November 2017.

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

  • Review the practice's responsibilities to take into account the needs of patients with disabilities and to comply with the requirements of the Equality Act 2010.
  • Review the practice's current performance review systems and have an effective process established for the on-going assessment and supervision of all.

7 November 2017

During a routine inspection

We carried out this announced inspection on 7 November 2017 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 principal dentist 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.

We told the NHS England area team that we were inspecting the practice. They did not provide any information.

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 not providing well-led care in accordance with the relevant regulations.

Background

Hillcrest Dental Surgery is in Wolverhampton and provides mainly orthodontic NHS and private treatment to patients of all ages.

There is a small step to gain access to the premises; the practice does not have a portable ramp for people who use wheelchairs and pushchairs. The practice does not have a car park but parking is available in local side roads.

The dental team includes one dentist (the principal dentist), two dental nurses, and one receptionist. The practice has two treatment rooms, only one of which is in use.

The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.

On the day of inspection we collected 46 CQC comment cards filled in by patients. This information gave us a positive view of the practice.

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

The practice is open: Monday 9am to 4pm and Tuesday to Thursday 9am to 5.30pm. The practice is closed for one hour each lunchtime.

Our key findings were:

  • The practice was clean and patients commented that this was always the case. There had been some damage to the windows of the practice (which were boarded up) due to a recent burglary.
  • Evidence was not available to demonstrate that all equipment was serviced or maintained in accordance with manufactures instructions.
  • The practice had infection control procedures which reflected published guidance.
  • Staff knew how to deal with emergencies. Not all of the required life-saving equipment was available.
  • The practice had some systems in place to help them manage risk although some risk assessments were overdue for review.
  • The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
  • The practice had a detailed staff recruitment policy but recruitment files did not demonstrate that the practice adhered to this policy on all occasions.
  • The clinical staff provided patients’ care and treatment in line with current guidelines, although the dentist was not grading or justifying the need to take X-rays in patient dental care records.
  • Staff appeared to have a good relationship with patients and staff were seen to speak with patients in a respectful manner. The door to the treatment room was left open when the dentist was with a patient and the computer on the reception desk was left on when the reception desk was not staffed.
  • The appointment system met patients’ needs.
  • Staff felt involved and supported and worked well as a team.
  • The practice asked patients for feedback about the services they provided.
  • We were told that the practice had not received any formal written complaints. Verbal complaints were dealt with as soon as they were received and details of these concerns were recorded on patient’s dental care records.

We identified regulations the provider was not meeting. They must:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulations the provider was not meeting are at the end of this report.

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

  • Review the practice’s protocols for the use of rubber dam for root canal treatment taking into account guidelines issued by the British Endodontic Society.
  • Review the practice’s protocols for recording in the patients’ dental care records or elsewhere the reason for taking the radiograph, the reporting and quality of the radiograph ensuring the practice is in compliance with the Ionising Radiation (Medical Exposure) Regulations (IRMER) 2000.
  • Review staff awareness of guidelines relating to competency principles when treating any child aged under 16 years and ensure all staff are aware of their responsibilities.
  • Review its responsibilities to the needs of people with a disability, including those with hearing difficulties and the requirements of the Equality Act 2010.

12 June 2014

During an inspection looking at part of the service

We previously inspected Hillcrest Dental Surgery on 19 September 2013. We found that the provider had a system in place to ensure potential cross infection was reduced. However, we saw that some instruments were visually unclean. Dental mirrors used by the dentists to help them see inside patient's mouth were cracked. We also observed that staff were not using the illuminated magnifying lamp to check whether instruments were clean before being sterilised. At the time we judged that this had a minor impact on patients who used the service. We set compliance actions and told the provider to take action.

At this inspection we spoke with the provider (who was also the dentist) and two dental nurses who also worked as reception staff. We saw that the issues identified in our previous inspection had now been addressed by the provider. A dental nurse we spoke with said they always used the illuminated magnifying lamp to decontaminate used instruments. This meant that they were able to visually inspect instruments to ensure that they were clean.

19 September 2013

During a routine inspection

We carried out this inspection to check on the treatment of people. Following the inspection we conducted telephone interviews with six people. On the day of the inspection we spoke with two trainee dental nurses and the dentist who was the provider.

The practice consisted of a reception/waiting area, two treatment rooms, a decontamination area and toilet facilities all on the ground floor. The practice did not have suitable facilities to meet Disability Discrimination Act requirements.

Records showed that people gave their consent for treatment. One person said, "The dentist always explains the treatment then I give my consent".

People we spoke with told us their treatment was "good". Records showed that people's treatment was recorded appropriately and highlighted where people needed further treatment or referrals made.

One person said, "The surgery is spotless". We found the environment to be clean and tidy. However some instruments were not visually clean.

The provider had a system in place to ensure only suitable staff were employed but the provider did not check references. This meant that the provider would not know if potential staff had the appropriate character and experience to deliver the job role.

The provider had a system in place to ensure staff had access to training, appraisals, development and appropriate induction.

Records showed there was a system to allow people to comment on the service they received.