The Care Quality Commission
  • Dentist
  • Dentist

Woodbridge Hill Dental Practice

49a Woodbridge Hill, Guildford, Surrey, GU2 9ZD

Provided and run by:
Dr Amirreza Farahani

All Inspections

15 November 2018

During a routine inspection

We carried out this unannounced inspection on 15 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

Woodbridge Hill Dental Practice is in Guildford, Surrey and provides NHS and private treatment to patients of all ages.

The practice is located on a first floor premises. Car parking spaces, including those for blue badge holders are on site.

The dental team includes the principal dentist, five associate dentists, two dental hygienists, one dental nurse, three trainee dental nurses and two receptionists. The practice has four 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 two dentists, one dental nurse, two trainee dental nurses and two receptionists. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

  • Monday to Saturday from 8am to 6pm

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 to patients and staff.
  • The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • The provider had staff recruitment procedures.
  • 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.
  • Staff were providing preventive care and supporting patients to ensure better oral health.
  • The appointment system took account of patients’ needs.
  • The principal dentist was responsible for clinical and managerial leadership.
  • The provider asked patients for feedback about the services they provided.
  • The provider had a system of dealing with complaints.
  • The provider had suitable information governance arrangements.

There were areas where the provider could make improvements. They should:

  • Review the practice's recruitment policy and procedures to ensure accurate, complete and detailed records are maintained for all staff.
  • Review the practice's policy for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken and the products are stored securely.
  • Review the practice's protocol and staff awareness of their responsibilities in relation to the Duty of Candour to ensure compliance with The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
  • Review the practice’s sharps procedures to ensure the practice is in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
  • Review the practice's current performance review systems and have an effective process established for the on-going assessment and supervision of all staff.

14 September 2017

During an inspection looking at part of the service

We carried out an announced follow-up inspection at Woodbridge Hill Dental Practice on 14 September 2017. This followed an announced comprehensive inspection on 15 February 2017 carried out as part of our regulatory functions where breaches of legal requirements were found.

We told NHS England and Healthwatch that we were inspecting the practice. NHS England shared with us information that we took into account.

After the comprehensive inspection, the practice wrote to us to say what actions they would take to meet the legal requirements in relation to the breaches.

We revisited Woodbridge Hill Dental Practice and checked whether they had followed their action plan.

We reviewed the practice against three of the five questions we ask about services: is the service safe, effective and well-led? This report only covers our findings in relation to those requirements.

You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Woodbridge Hill Dental Practice on our website at www.cqc.org.uk.

Background

This inspection was planned to check whether the practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The follow-up inspection was led by a CQC inspector who was supported by a specialist dental advisor.

During our inspection visit, we checked that points described in the provider’s action plan had been implemented by looking at a range of documents such as risk assessments, staff files, policies and staff training.

Our key findings were:

The practice appeared clean.

  • The practice had infection control procedures. Some improvements were required in order that procedures followed reflected published guidance.
  • Staff knew how to deal with emergencies. All appropriate medicines and most of the required 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 staff recruitment procedures which reflected relevant legislation.
  • Improvements had been made to the governance arrangements at the practice.

We found areas where the provider could make improvements and should:

  • Review the storage of dental care products and medicines requiring refrigeration to ensure they are stored in line with the manufacturer’s guidance and the fridge temperature is monitored and recorded.
  • Review availability of equipment to manage medical emergencies taking into account guidelines issued by the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.
  • Review the infection control procedures and protocols carried out by newly employed staff to take into account guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and have regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’.
  • Review the practice protocols to ensure the training, learning and development needs of individual staff members are reviewed at appropriate intervals and an effective process is established for the on-going assessment and supervision of all staff.
  • Review the processes and systems in place for seeking and learning from staff feedback with a view to monitoring and improving the quality of the service.
  • Review the practice’s protocols for the use of closed circuit television cameras (CCTV) taking into account guidelines published by the Information Commissioner's Office (ICO).

15 February 2017

During a routine inspection

We carried out an announced comprehensive inspection on 15 February 2017 to ask the practice the following key questions; Are services safe, effective, caring, responsive and well-led?

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 not providing well-led care in accordance with the relevant regulations.

Background

Woodbridge Hill Dental Practice provides private and NHS treatment to both adults and children in Guildford. The practice is located on first floor premises accessed by an internal stair case. There are five treatment rooms one of which has been decommissioned, a waiting room with separate reception area and a separate decontamination room. The practice is open between 8.30am and 6pm Monday to Friday.

The practice consists of the principal dentist, two associate dentists, two dental nurses, a dental hygienist, a trainee dental nurse and two receptionists. At the time of our inspection the practice did not have a practice manager. The principal dentist had taken over the practice seven months prior.

The principal dentist was the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons 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 inspection took place over one day and was carried out by a CQC inspector and a dental specialist advisor.

We received feedback from four patients about the service. The feedback was positive and patients commented on the friendly and helpful reception staff. Additionally, patients commented that they felt listened to and that the service they received was good.

Our key findings were:

  • Patients were treated with dignity and respect and confidentiality was maintained.
  • There was a process in place for the reporting of untoward incidents that occurred in the practice.
  • The dental care records we saw appeared to show that dentists provided dental care in accordance with current professional and National Institute for Care Excellence (NICE) guidelines.
  • The practice had most emergency medicines in line with the British National Formulary (BNF) guidance for medical emergencies in dental practices. However not all staff had received adequate training in medical emergencies.
  • The practice had some processes in place for safeguarding adults and children living in vulnerable circumstances although not all staff had received safeguarding training nor were they aware of the procedures to follow.
  • Improvements could be made to the practice’s decontamination procedures to ensure staff were following national guidance for infection prevention and control in dental practices
  • There was no structured plan to gain feedback from staff for the purpose of making continual improvements.
  • New staff did not receive an induction upon commencing working at the practice.
  • Staff had not received an appraisal and there was no structured monitoring of training completed by staff and no system to identify training needs.
  • The practice had not completed a fire evacuation drill since June 2016, during which time the practice had recruited several new staff members.

We identified regulations that were not being met and the provider must:

  • Ensure the training, learning and development needs of individual staff members are reviewed at appropriate intervals and an effective process is established for the on-going assessment and appraisal of all staff.
  • Ensure that the staffing levels are reviewed to ensure that there are sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the needs of patients.
  • Ensure the practice establishes an effective system to assess, monitor and mitigate the various risks arising from undertaking of the regulated activities.
  • Ensure systems are in place to assess, monitor and improve the quality of the service such as undertaking regular audits of various aspects of the service and ensuring that where appropriate audits have documented learning points and the resulting improvements can be demonstrated.

There were areas where the provider could make improvements and should:

  • Review the practice’s arrangements for receiving and responding to patient safety alerts, recalls and rapid response reports issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and through the Central Alerting System (CAS), as well as from other relevant bodies, such as Public Health England (PHE).
  • Review current systems to ensure internal communication and shared learning are promoted amongst the practice staff.
  • Review current systems to ensure that feedback from patients and staff is sought and acted on for the purposes of continually evaluating and improving services.