Archived: Short Heath Dental Practice

Updated 29 December 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. 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.

We inspected Short Heath Dental Practice on 27 October 2016. The inspection was carried out by a Care Quality Commission (CQC) inspector and a dental specialist advisor.

Prior to the inspection we reviewed information we held about the provider from various sources. We informed NHS England that we were inspecting the practice. We also requested details from the provider in advance of the inspection. This included their latest statement of purpose describing their values and objectives and a record of patient complaints received in the last 12 months.

During the inspection we toured the premises, spoke with the practice manager (who has been the CQC registered manager since 2014), the area manager, one dentist and two dental nurses. We also reviewed CQC comment cards which patients had completed and spoke with patients. We reviewed a range of practice policies and practice protocols and other records relating to the management of the service.

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 therefore formed the framework for the areas we looked at during the inspection.

Updated 29 December 2016

We carried out an announced comprehensive inspection on 27 October 2016 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 providing well-led care in accordance with the relevant regulations.

Background

Short Heath Dental Practice is a dental practice providing general dental services on a NHS and private basis. The service is provided by two dentists. They are supported by five dental nurses (two of whom are trainees) and a practice manager. All of the dental nurses also carry out reception duties.

The practice is located in a residential area. The practice offers access to patients with limited mobility as it is situated on the ground floor; however, it cannot accommodate wheelchair users. There are car parking facilities outside the practice. The premises consist of a waiting room, a reception area, an office, kitchen, decontamination room, toilet facilities and two treatment rooms. The practice’s opening hours were from 8:30am to 5pm on Monday to Friday.

The practice manager is the registered manager. A registered manager is a person who is registered with the Care Quality Commission (CQC) 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.

Thirteen patients provided feedback about the practice. We looked at comment cards patients had completed prior to the inspection and we also spoke with four patients. The information from patients was generally complimentary. Patients were positive about their experience and they commented that staff were friendly and caring.

Our key findings were:

• The practice appeared clean and tidy on the day of our visit. Patients also commented that this was their experience.
• Patients told us they found the staff polite and friendly. Patients were able to make routine and emergency appointments when needed.
• An infection prevention and control policy was in place. We saw the decontamination procedures followed recommended guidance although we identified some improvements were required.
• The practice had systems to assess and manage risks to patients, including health and safety, safeguarding, safe staff recruitment and the management of medical emergencies. Some necessary improvements were required.
• Staff received training appropriate to their roles.
• There was appropriate equipment for staff to undertake their duties, and equipment was well maintained.
• The practice had an effective complaints system in place and there was an openness and transparency in how these were dealt with.
• Staff told us they felt well supported and comfortable to raise concerns or make suggestions.
• Practice meetings were used for shared learning.
• The practice demonstrated that they regularly undertook audits in infection control, radiography and dental care record keeping.

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

• Review availability of medicines to manage medical emergencies giving due regard to guidelines issued by the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.
• Review stocks of equipment and the system for identifying and disposing of expired stock.
• Review the practice’s protocols for the use of rubber dam for root canal treatment giving due regard to guidelines issued by the British Endodontic Society.
• Review the training, learning and development needs of individual staff members and have an effective process established for the on-going assessment and supervision of all staff.
• Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and Gillick competency and ensure all staff are aware of their responsibilities as it relates to their role.
• Review the practice's protocols for completion of dental records giving due regard to guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.
• Review the legionella risk assessment upon completion and implement the required actions including the monitoring and recording of water temperatures, giving due regard to the guidelines issued by the Department of Health – ‘Health Technical Memorandum 01-05: Decontamination in primary care dental practices’ and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’.