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Inspection Summary


Overall summary & rating

Updated 23 October 2017

We carried out a follow-up inspection at Villa Dental Suite Ltd on 6 October 2017.

We had undertaken an announced comprehensive inspection of this service on 27 February 2017 as part of our regulatory functions where a breach of legal requirements was found.

After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach. This report only covers our findings in relation to those requirements. We checked whether they had followed their action plan to confirm that they now met the legal requirements.

We reviewed the practice against one of the five questions we ask about services: are the services well led? You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Villa Dental Suite Ltd on our website at www.cqc.org.uk.

We revisited Villa Dental Suite Ltd as part of this review and checked whether they now met the legal requirements. We carried out this announced inspection on 6 October 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 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.

• Is it well-led?

This question forms the framework for the areas we look at during the inspection.

Our findings were:

Are services well-led?

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

Background

Villa Dental Suite Ltd is in Bingley and provides private treatments to adults and children. Treatments include dental implants and conscious sedation.

There is level access for people who use wheelchairs and pushchairs. The practice has a dedicated car park for patients.

The dental team includes three dentists, four dental nurses, one dental hygienist, one receptionist and a practice manager. The practice has four 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 Villa Dental Suite Ltd was the practice manager.

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

The practice is open:

Monday to Friday from 9:00am to 6:00pm

Saturday from 9:00am to 12:30pm

Our key findings were:

  • Medicines were now stored securely.
  • Decontamination and infection control procedures had been reviewed and now followed nationally recognised guidance.
  • An infection prevention and control audit had been carried out.
  • The practice had reviewed staff recruitment procedures. All staff now had Disclosure and Barring Service (DBS) checks.
Inspection areas

Safe

No action required

Updated 28 April 2017

We found that this practice was providing safe care in accordance with the relevant regulations.

There were systems in place to assess and manage risks.

X-ray equipment was regularly maintained.

The decontamination procedures were effective and the equipment involved in the decontamination process was regularly serviced. Improvements could be made to validation and checks to ensure equipment was safe to use.

There were maintenance contracts in place to ensure all equipment had been serviced regularly, including; autoclaves, fire extinguishers, and the air compressor.

Staff were appropriately skilled and suitably trained and qualified for their roles. We noted that the practice had not undertaken all of the relevant recruitment checks to ensure patient safety including DBS checks or references for staff.

There was evidence to demonstrate staff had attended training in safeguarding patients and understood their responsibilities in relation to identifying and reporting any potential abuse.

Effective

No action required

Updated 28 April 2017

We found that this practice was providing effective care in accordance with the relevant regulations.

The practice followed current guidelines when delivering dental care and treatment to patients. Patients’ medical history was recorded at their initial visit and updated at subsequent visits. Patients received an assessment of their dental health. The dentists obtained consent from patients before treatment was provided; and treatment focused on the patients’ individual needs.

Staff provided oral health advice to patients and monitored changes in their oral health. Patients were referred to other services, where necessary, in a timely manner.

Staff were encouraged to complete training relevant to their roles. The clinical staff were up to date with their continuing professional development (CPD).

Qualified staff were registered with their professional body, the General Dental Council, and were supported in meeting the requirements of their professional regulator.

Caring

No action required

Updated 28 April 2017

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

Staff explained that enough time was allocated in order to ensure treatment was fully explained to patients in a way patients understood. Time was given to patients with complex treatment needs to decide which treatment they preferred.

Staff understood the importance of emotional support when delivering care to patients who were nervous of dental treatment. Patient feedback on CQC comment cards confirmed staff were understanding and made them feel at ease.

We observed privacy and confidentiality were maintained for patients in reception and over the telephone. Policies and procedures in relation to data protection and security and confidentiality were in place and staff were aware of these.

Responsive

No action required

Updated 28 April 2017

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

The practice had an efficient appointment system in place to respond to patients’ needs. There were vacant appointments slots for urgent or emergency appointments each day. Patients could request appointments by telephone or in person.

The practice opening hours were displayed at the practice and in the patient information leaflet.

The practice produced a quarterly newsletter keeping their patients updated about treatments, inviting feedback and suggestions and introducing new staff.

We saw that the practice invited patients to bring their concerns to the practice manager. There was a procedure in place for responding to patients’ complaints. This involved acknowledging, investigating and responding to individual complaints or concerns.

Well-led

No action required

Updated 23 October 2017

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

The practice demonstrated that medicines (including those used in conscious sedation) were now stored securely.

We found the practice had reviewed and improved the process for checking the decontamination equipment to ensure it was safe to use. This now followed nationally recognised guidance.

An infection prevention and control audit had been completed.

The practice had reviewed its recruitment policy and process. All staff now had a DBS check and references.