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Archived: Active Smile

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Inspection report

Date of Inspection: 20 November 2013
Date of Publication: 3 January 2014
Inspection Report published 03 January 2014 PDF

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 20 November 2013, checked how people were cared for at each stage of their treatment and care and sent a questionnaire to people who use the service. We talked with people who use the service and talked with staff.

Our judgement

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

Reasons for our judgement

We reviewed the quality assurance policy and procedures for the Practice. As part of the quality assurance system we saw that risk assessments were reviewed regularly, as were the required policies and procedures. A range of audits was carried out to ensure systems were working effectively within the Practice.

We saw clear evidence of quality monitoring of the routine decontamination processes for equipment. We also saw that risk assessments had been completed for health and safety, including radiation safety and hazardous substances. Records showed systems were in place for areas which used external accredited contractors to check for compliance which included checks on water systems for legionella and there were systems in place to monitor the management of drugs and equipment.

The Provider had undertaken a satisfaction survey of a random sample of patients. We looked at a selection of completed questionnaires and we saw that the results were very positive. The results of the survey had been analysed and any comments had been addressed. The Practice Manager told us they planned to carry out the patient satisfaction survey on an annual basis.

The Provider had a clear Complaints policy. The policy encouraged all concerns to be raised as quickly as possible with a member of staff. If any concerns or questions could not be resolved immediately and informally, the matter should be referred to the Practice Manager. The Complaints policy was included in the information folder made available in the patient’s waiting room. The Practice Manager told us any concerns about procedures had been resolved satisfactorily.

The Provider told us that they had considered plans to introduce a newsletter for patients, to keep them up-to-date with any changes or developments within the practice. The Practice Manager told us how the views of the patients would be taken into account for future needs and from the patient surveys.

This meant that the Provider had demonstrated a clear understanding of the benefits of a comments and complaints system as a learning and developmental opportunity.