Archived: Rookery Road Dental Surgery

Updated 7 July 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 Rookery Road Dental Surgery on 26 April 2016. The inspection team consisted of one 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 this 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 previous 12 months.

During the inspection we toured the premises, spoke with the practice manager, one dentist and two dental nurses. We also spoke with patients. We reviewed a range of practice policies and practice protocols and other records relating to the management of the service. We announced this inspection two weeks prior to our visit and we were told the provider would be present during our visit. However, the practice manager contacted us a few days later and informed us that the provider had to attend urgent business elsewhere and would not be available on the day of our visit.

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 7 July 2016

We carried out an announced comprehensive inspection on 26 April 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

Rookery Road Dental Surgery is a mixed dental practice providing NHS and private dental treatment for both adults and children. The service is provided by two dentists. They are supported by a practice manager (who works part-time at this practice) and two dental nurses. The dental nurses also carry out reception duties.

The practice can accommodate patients with restricted mobility. The premises consist of a reception area, waiting room, toilet facilities, one treatment room and a staff room on the ground floor. The first floor comprises of two treatment rooms, a decontamination room and toilet facilities for staff. There is also an office on the second floor. There is free parking near the practice. Opening hours are from 9:30am to 4pm from Monday to Friday.

The provider is registered with the Care Quality Commission (CQC) as an individual. 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.

Two patients provided feedback about the practice. Although we sent comment cards to the practice ahead of our inspection none had been completed. We spoke with patients on the day of the inspection. Overall the information from patients was complimentary. Patients were positive about their experience and they commented that staff were polite and good with children.

Our key findings were:

• Equipment for dealing with medical emergencies mainly followed published guidance. We highlighted areas of improvement and these were dealt with promptly.
• The practice was visibly clean on the day of our visit.
• Patients were able to make routine and emergency appointments when needed.
• Patients’ care and treatment was planned and delivered in line with evidence based guidelines, best practice and current legislation.
• Staff demonstrated knowledge of whistleblowing and safeguarding and were confident they would raise concern if necessary.
• Patients told us they found the staff polite.
• Staff received training appropriate to their roles.
• The practice had a complaints system in place.
• Staff told us they felt well supported and comfortable to raise concerns or make suggestions.
• The practice demonstrated that they regularly undertook audits in infection control and radiography. No learning points had been documented.
• An infection control policy was in place and procedures followed mainly reflected published guidance. We highlighted areas requiring improvement.

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

• Review stocks of medicines and equipment and the system for identifying and disposing of out-of-date stock.
• Review the practice’s infection control procedures and protocols giving due regard to 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.
• Review its responsibilities as regards to the Control of Substance Hazardous to Health (COSHH) Regulations 2002 and, ensure all documentation is up to date and staff understand how to minimise risks associated with the use of and handling of these substances.
• Review the practice’s protocols of various aspects of the service at regular intervals to help improve the quality of service. A robust system should be used to monitor and mitigate risks arising from undertaking of the regulated activities. The practice should also check all audits have documented learning points and the resulting improvements can be demonstrated.
• Review the practice's recruitment policy and procedures to ensure recruitment checks for new staff are suitably obtained and recorded.