Updated 10 October 2017
We carried out this announced inspection on 26 September 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 who was supported by a specialist dental adviser.
We told the NHS England area team and Healthwatch that we were inspecting the practice. They did not provide any information of concern.
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
Belle Isle Family Dental Practice is in Leeds and provides NHS and private treatment to adults and children. They also have an NHS contract to provide orthodontic treatment.
There is level access for people who use wheelchairs and pushchairs. The practice has a dedicated car park.
The dental team includes three dentists, five dental nurses (one of whom is a trainee), one dental hygiene therapist and one receptionist. The practice has three 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 Belle Isle Family Dental Practice was the principal dentist.
On the day of inspection we received feedback from six patients. This information gave us a positive view of the practice.
During the inspection we spoke with two dentists, 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 to Friday from 8:30am to 5:00pm
Our key findings were:
- The practice was clean and well maintained.
- The practice 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. Improvements could be made to the process for reducing risks associated with Legionella.
- The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
- 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.
- The appointment system met patients’ needs.
- The practice had effective leadership. 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 dealt with complaints positively and efficiently.
There were areas where the provider could make improvements and should:
- Review the current legionella risk assessment and implement the required actions including the monitoring and recording of water temperatures, giving due regard to the guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.
- Review the practice's recruitment policy and procedures to ensure Hepatitis B titre levels for new staff are requested and recorded suitably.
- Review its responsibilities to the needs of people with a disability and the requirements of the equality Act 2010.