Updated 4 December 2018
We carried out this announced inspection on 6 November 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
The Poplars Dental Practice is in Rodley, on the outskirts of Leeds, and provides NHS treatment to adults and children, with some private treatment for adults.
There is level access for people who use wheelchairs and those with pushchairs. Car parking and public transport facilities are available near the practice.
The dental team includes three dentists, three dental nurses (one of whom is a trainee), one dental hygienist, one dental therapist, a practice manager and a receptionist. The practice has three treatment rooms.
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.
During the inspection we spoke with the principal dentist, one dental hygienist, two dental nurses and the practice manager. We looked at the practice’s policies and procedures and other records about how the service is managed.
The practice is open:
Monday 8:30am-7pm, Wednesday 8:30am-1pm and Tuesday, Thursday, Friday 8:30am- 5pm
On the day of inspection, we collected 24 CQC comment cards filled in by patients.
Our key findings were:
- The practice appeared clean and well maintained.
- The provider had infection control procedures which reflected published guidance.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- The practice had systems to help them manage risk with the exception of lone working risk assessments.
- The provider had staff recruitment procedures in place.
- The practice staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children. The safeguarding policy needed to include vulnerable adults,
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Staff treated patients with dignity and respect.
- 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 a 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.
- Clinical and non-clinical audits were completed.
- The practice staff had suitable information governance arrangements.
There were areas where the provider could make improvements. They should:
- Review the practice's protocols for monitoring and recording the fridge temperature to ensure that medicines and dental care products are being stored in line with the manufacturer’s guidance.
- Review the practice’s systems for assessing, monitoring and mitigating the various risks arising from the undertaking of the regulated activities. In particular undertaking risk assessments for staff who work alone.
- Review the practice’s safeguarding policy and ensure it takes into account both adults and children.