5 June 2018
During a routine inspection
We carried out this announced inspection on 5 June 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
Elli and Associates is in Oldham and provides NHS and private treatment to adults and children.
The practice is located in premises on a high street with surrounding shops and businesses. Access is via a small step, there are arrangements for people who use wheelchairs to access care. On street parking is available near the practice.
The dental team includes two dentists, four dental nurses who also carry out reception and administrative duties and a part time dental hygiene therapist. The practice has two treatment rooms.
The practice is owned by a company and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers 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 registered manager at Elli and Associates was the principal dentist.
On the day of inspection, we collected eight CQC comment cards filled in by patients and spoke with two patients.
During the inspection we spoke with both dentists and three dental nurses. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday to Thursday 9:00am to 5:30pm
Friday 9:00am to 2:30pm
Our key findings were:
- The practice appeared clean and well maintained.
- The practice staff 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.
- The practice staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
- The practice had thorough 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.
- The practice was providing preventive care and supporting patients to ensure better oral health.
- The appointment system met patients’ needs.
- The practice had effective leadership and culture of continuous improvement.
- Staff felt involved and supported and worked well as a team.
- The practice asked staff and patients for feedback about the services they provided.
- The practice had systems to deal with complaints positively and efficiently.
- The practice staff had suitable information governance arrangements.
There were areas where the provider could make improvements. They should:
- Review the practice’s arrangements for receiving and responding to patient safety alerts, recalls and rapid response reports issued by the Medicines and Healthcare products Regulatory Agency, the Central Alerting System and other relevant bodies, such as Public Health England.
- Review the practice’s protocols for ensuring that all clinical staff have adequate immunity for vaccine preventable infectious diseases.
- 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 security of NHS prescription pads in the practice and ensure there are systems in place to track and monitor their use.
- Review the practice’s protocols to ensure audits of radiography and infection prevention and control to ensure that audits have documented learning points and the resulting improvements can be demonstrated.