Archived: Bradley Shorthouse Dental Clinic

Updated 28 January 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.

The inspection was carried out on 27 October 2015 by a CQC inspector and a dentist specialist advisor. Before the inspection we reviewed information we held about the provider and information that we asked them to send us in advance of the inspection. We informed the local NHS England area team that we were inspecting the practice. They did not have any concerning information to provide about the practice.

During the inspection we spoke with members of the practice team including dentists, dental nurses, reception staff and the practice manager. We looked around the premises including the treatment rooms. We reviewed a range of policies and procedures and other documents and read the comments made by 52 patients on comment cards provided by CQC before the inspection and in 58 Share Your Experience forms that patients had completed using our website. We also looked at the practice’s NHS Friends and Family survey results for April to September 2015.

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 28 January 2016

We carried out an announced comprehensive inspection on 27 October 2015 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

This report is about the service provided at Bradley Shorthouse Dental Clinic in Kidderminster town centre.

The practice has four dentists, three dental hygienists (one of whom is also a dental therapist) and nine dental nurses, one of whom is a trainee. The clinical team are supported by a practice manager and receptionist. Two of the dental nurses also work as receptionists and another is the assistant practice manager. The practice has four dental treatment rooms and a decontamination room for the cleaning, sterilising and packing of dental instruments. The reception area and waiting room are on the ground floor.

Before the inspection we sent Care Quality Commission comment cards to the practice for patients to use to tell us about their experience of the practice. We collected 52 completed cards. We also received information from 58 patients who filled in Share Your Experience forms on our website. Without exception patients were complimentary about the practice and their experience of being a patient there. People described receiving a professional, caring and efficient service and many commented that they could not speak highly enough of the dentists and other members of the practice team. Many patients described being listened to and feeling confident that their dentist provided treatment which met their needs.

Our key findings were:

• Patients who gave us feedback were pleased with the care and treatment they received and complimentary about the whole practice team.

• The practice had an established process for reporting and recording significant events and accidents to ensure they investigated these and took remedial action. The practice used significant events to make improvements and shared learning from these with the team.
• The practice was visibly clean and a number of patients commented on their satisfaction with hygiene and cleanliness.

• The practice had well organised systems to assess and manage infection prevention and control.

• The practice had suitable safeguarding processes and staff understood their responsibilities for safeguarding adults and children.

• The practice had recruitment policies and procedures and used these to help them check the staff they employed were suitable. The practice obtained the correct information for new staff but their written policy and procedures did not fully reflect the requirements of legislation.

• Dental care records provided information about patients’ care and treatment.

• Staff received training appropriate to their roles and were supported in their continued professional development.

• Patients were able to make routine and emergency appointments when needed.

• The practice had systems including audits to assess, monitor and improve the quality and safety of the services provided.

• The practice had systems to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients, staff and visitors.

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

• Review the practice’s sharps procedures giving due regard to the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
• 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.

• Introduce comprehensive audits of radiography at regular intervals to identify learning points and help improve the quality of service.
• Review the practice’s recruitment policy to fully reflect the requirements of Regulation 19(3) and Schedule 3 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014.