29/05/2018
During a routine inspection
We carried out this announced inspection on 29 May 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
Dawley Dental Practice is in Telford and provides NHS and private treatment to adults and children.
There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice.
The dental team includes six dentists, seven dental nurses, two dental hygienists, one dental hygiene therapist, one practice manager and two receptionists. The practice has 7 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 Dawley Dental Practice was the principal dentist.
On the day of inspection, we collected 33 CQC comment cards filled in by patients.
During the inspection we spoke with two dentists, three dental nurses, one receptionist and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Our key findings were:
- The practice appeared clean and well maintained.
- The practice had infection control procedures which reflected published guidance. Some improvements were required with the testing of equipment but these were promptly resolved.
- 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 were required in some areas and these issues were resolved promptly.
- The practice staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
- The practice had staff recruitment procedures. The processes were not always consistent.
- 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 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 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.
- Staff dealt with complaints positively and efficiently.
- The practice staff had suitable information governance arrangements.
There were areas where the provider could make improvements. They should:
- Review the current Legionella risk assessment and implement the required actions including the monitoring and recording of water temperatures.
- Review the systems for checking and monitoring equipment taking into account current national guidance and ensure that all equipment is well maintained.
- Review the practice’s protocols for recording in the patients’ dental care records or elsewhere the reason for taking the X-ray and quality of the X-ray ensuring compliance with the Ionising Radiation (Medical Exposure) Regulations (IRMER) 2000.
- Review the practice’s system for recording, investigating and reviewing incidents or significant events with a view to preventing further occurrences and ensuring that improvements are made as a result.
- Review the practice's recruitment policy and procedures to ensure accurate, complete and detailed records are maintained for all staff.