Updated 27 February 2018
We carried out this announced inspection on 22 January 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.
We told the NHS England we were inspecting the practice. They provided information which we took into account.
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
Haynesdental - Thurlow Park Road is located in West Dulwich and provides NHS and private treatment to patients of all ages. The practice undertakes general dentistry and dental implants.
There is access for people who use wheelchairs and those with pushchairs.
The dental team includes six dentists, five dental nurses, two dental hygienists, two receptionists. An assistant practice manager and a practice manager. The practice has four treatment rooms.
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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. At the time of the inspection the practice did not have a registered manager in post.
On the day of inspection we collected 16 CQC comment cards filled in by patients and spoke with three other patients. This information gave us a positive view of the practice.
During the inspection we spoke with a dentist, two dental nurses, two receptionists, a provider compliance lead and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open Mondays and Fridays 8.00 - 17.00; tuesday – thurday 8.00 – 20.30 and Saturdays 9.00 – 15.00.
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.
- The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
- The practice had thorough staff recruitment procedures.
- The clinical staff provided patients’ care and treatment in line with current guidelines.However improvements were required in regards to record keeping.
- 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. They should:
- Review the practice's current audit protocols to ensure audits of key aspects of service delivery are undertaken at regular intervals and where applicable learning points are documented and shared with all relevant staff.
- Review stocks of medicines and equipment and the system for identifying, disposing and replenshing of out-of-date stock.
- Review the practice’s protocols for the use of rubber dam for root canal treatment taking into account guidelines issued by the British Endodontic Society.
- Review the practice's protocols for completion of dental care records taking into account guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.