Archived: Mr Michael South - Kirkstall Road

We carried out this announced inspection on 6 November 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

MW South dental practice is in Leeds and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and pushchairs. Car parking spaces are available near the practice.

The dental team includes two dentists, four dental nurses (two of which are trainees) and two receptionists. The practice has three treatment rooms and two instrument decontamination 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.

On the day of inspection we collected 46 CQC comment cards filled in by patients and spoke with two patients. This information gave us a positive view of the practice.

During the inspection we spoke with two dentists, two dental nurses and a receptionist. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday and Friday 08:30 – 13:15, Tuesday to Thursday 08:30 – 17:45

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 some systems to help them manage risk but improvements could be made.
• The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
• The practice had thorough staff recruitment procedures.
• Improvement was required when providing care and treatment to bring processes in line with recommended guidance.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• The use of rubber dam was not in line with guidelines issues by the British Endodontic Society.
• The appointment system met patients’ needs.
• Management processes and leadership could be improved. 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 protocols for the use of rubber dam for root canal treatment taking into account guidelines issued by the British Endodontic Society.
• Review current procedures to ensure a system is in place to track and monitor prescription use.
• Review the practice's policy and the storage of products identified under Control of Substances Hazardous to Health (COSHH) 2002 Regulations to ensure a risk assessment is undertaken and the products are stored securely.
• 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.
• Review the practice protocols and adopt an individual risk based approach to patient recalls taking into account National Institute for Health and Care Excellence (NICE) guidelines.