15 June 2017
During a routine inspection
We carried out this announced inspection on 15 June 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 Cheshire and Merseyside area team and Healthwatch that we were inspecting the practice. We did not receive any information of concern from them.
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
Wentworth Dental Practice is close to the centre of Wilmslow and provides treatment to patients of all ages on an NHS or privately funded basis.
There are steps at the front entrance to the practice with a handrail positioned alongside to assist patients with limited mobility. The provider has also installed a ramp to facilitate access to the practice for wheelchair users and for pushchairs. Car parking is available outside the practice.
The dental team includes five dentists, one dental hygienist / therapist, three dental nurses and one receptionist. The practice has three treatment rooms. The team is supported by an operations manager.
The practice is owned by a company and as a condition of registration must have in place a person registered with the Care Quality Commission as the registered manager. Registered managers have a 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.
We received feedback from 28 people during the inspection about the services provided. The feedback provided was positive about the practice.
During the inspection we spoke to two dentists, two dental nurses and the operations manager. We looked at practice policies, procedures and other records about how the service is managed.
The practice is open: Monday to Friday 8.45am to 5.00pm.
Our key findings were:
- The practice was clean and well maintained.
- The practice had infection control procedures in place which reflected published guidance.
- Staff knew how to deal with emergencies. Medical emergency medicines and equipment were available.
- The practice had safeguarding processes in place and staff knew their responsibilities for safeguarding adults and children.
- Staff provided patients’ care and treatment in line with current guidelines.
- The practice had a procedure in place for dealing with complaints.
- Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
- The appointment system took patients’ needs into account. Dedicated emergency appointments were available.
- The practice had a leadership structure. Staff felt involved and supported and worked well as a team.
- The practice asked patients and staff for feedback about the services they provided.
- The practice had systems in place to help them manage risk. Improvements could be made to measures for mitigating risk.
- The practice had staff recruitment procedures in place. Minor improvements could be made to these.
There were areas where the provider could make improvements and should:
- Review the practice’s system for the recording, investigating and reviewing of incidents and significant events with a view to preventing further occurrences.
- Review the practice’s systems for assessing, monitoring and mitigating the various risks arising from undertaking of the regulated activities, specifically in relation to Legionella, and to staff immunity to the Hepatitis B virus.
- Review the protocol for completing accurate, complete and detailed records relating to the employment of staff. This includes making appropriate notes of verbal references taken and ensuring recruitment checks, including references, are suitably obtained and recorded.
- Review the practice’s systems to ensure staff are up to date with their training and continuing professional development.
- Review the practice’s audit protocols to ensure they include documented learning points where appropriate, and the resulting improvements can be demonstrated.