All inspections: The Willows Dental Practice

We undertook a follow up desk-based inspection of The Willows Dental Practice on 22 April 2020. This inspection was carried out to review in detail the actions taken by the registered provider to improve the quality of care and to confirm that the practice was now meeting legal requirements.

The inspection was led by a CQC inspector who had access to a specialist dental adviser.

We undertook a comprehensive inspection of The Willows Dental Practice on 19 December 2019 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We found the registered provider was not providing well led care and was in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can read our report of that inspection by selecting the 'all reports' link for The Willows Dental Practice on our website www.cqc.org.uk.

As part of this inspection we asked:

• Is it well-led?

When one or more of the five questions are not met, we require the service to make improvements and send us an action plan. We then inspect again after a reasonable interval, focusing on the areas where improvement was required.

Are services well-led?

We found this practice was providing well-led care in accordance with the relevant regulations.

The provider had made improvements in relation to the regulatory breach we found at our inspection on 19 December 2019.

Background

The Willows Dental Practice is in Belton, Doncaster and provides private dental care and treatment for adults and children.

There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for people with disabilities, are available at the practice.

The dental team includes two dentists, five dental nurses and one dental hygiene therapist. The practice has two 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.

We reviewed updated documents which included policies, procedures and photographs submitted as evidence by the provider.

The practice is open:

Monday and Thursday 9am to 5:15pm, Tuesday and Wednesday 9am to 5pm and Friday 9am to 12:15pm.

Our key findings were:

Legionella management systems complied with guidance.
Fire safety systems complied with current regulations.
Safer sharps systems were effective and reflected current regulations.
The system to ensure appropriate medicines and equipment were in place was effective.
The provider reviewed the current systems for recording, investigating and reviewing incidents or significant events with a view to preventing further occurrences.
Clinical waste was managed and disposed of in line with guidance.
The system to manage audit for quality assurance, learning and improvement was embedded.
The provider had implemented systems to ensure staff continued to meet the professional standards.
Leadership and clinical oversight were effective.

We carried out this announced inspection on 19 December 2019 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 Care Quality Commission, (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 this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

We found this practice was providing effective care in accordance with the relevant regulations.

Are services caring?

We found this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found this practice was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found this practice was not providing well-led care in accordance with the relevant regulations.

Background

The Willows Dental Practice is in Belton, Doncaster and provides private dental care and treatment for adults and children.

There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for people with disabilities, are available at the practice.

The dental team includes two dentists, five dental nurses and one dental hygienist. The practice has two 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.

On the day of inspection, we collected 50 CQC comment cards filled in by patients. All comments reflected positively on the service provided.

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

The practice is open: Monday and Thursday 9am to 5:15pm, Tuesday and Wednesday 9am to 5pm and Friday 9am to 12:15pm.

Our key findings were:

The practice appeared to be visibly 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.
Systems to help them manage risk to patients and staff could be improved, in particular: significant event awareness, safer sharps handling, clinical waste and legionella management and fire safety procedures.
The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
Oversight of continuous professional development training could be improved, in particular: infection prevention and control and safeguarding.
The provider had staff recruitment procedures which reflected current legislation.
The clinical staff provided patients’ care and treatment in line with current guidelines.
Awareness of responsibilities under the Mental Capacity Act 2005 and Power of Attorney could be improved.
Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
Staff provided preventive care and supported patients to ensure better oral health.
The appointment system took account of patients’ needs.
Effective leadership and clinical oversight could be improved.
The practice’s culture of continuous improvement was not embedded.
Staff felt involved and supported and worked as a team.
The provider asked staff and patients for feedback about the services they provided.
The provider dealt with complaints positively and efficiently.
The provider had information governance arrangements.

We identified regulations the provider was not complying with. They must:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

Full details of the regulation the provider is not meeting are at the end of this report.

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

Review the practice’s protocols for the use of closed-circuit television cameras taking into account the guidelines published by the Information Commissioner's Office.

Patients confirmed they were asked for their consent before any treatment was undertaken and they received information from the dentist about choices of treatment.

Patients spoke very positively about being seen promptly and about their dental care and treatment. One patient told us, 'Everything is first class; it looks like a professional practice.' Another patient said, 'The dentist is pretty good at keeping me advised of what I should and shouldn't do.'

Comments from patients about cleanliness included, 'Cleanliness is first class,' 'It looks immaculate,' 'Very impressed with cleanliness,' 'It is spotless,' 'Cleanliness is very good,' and 'We can't see any dirt at all.'

Patients spoke positively about the staff that worked with them. Patient comments included, 'Staff are very personable and professional and they are always happy,' 'I can't fault the staff they put you at ease; they are so friendly and take a genuine interest,' 'The staff are always friendly and very professional,' 'The dentist is really good and very professional,' and 'The staff speak to me by name.'

Patient comments we reviewed included, 'Having been terrified of dentists all my life I now actually enjoy my visits,' 'My treatment was excellent; I am delighted with my new tooth,' 'They are very good because they understand what you need.' 'Can't speak highly enough of this practice,' 'Would recommend this practice,' and 'Very professional in all aspects.'

Archived: The Willows Dental Practice

All Inspections

22 April 2020

During an inspection looking at part of the service

19 December 2019

During a routine inspection

1 October 2013

During a routine inspection