Background to this inspection
Updated
26 October 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 carried out an announced, comprehensive inspection on 21September 2016. The inspection was carried out by a CQC inspector and a dental specialist advisor. Prior to the inspection we reviewed information submitted by the provider.
During our inspection visit, we reviewed policy documents and staff records. We spoke with five members of staff, which included the principal dentist, an associate dentist, two dental nurses, and the receptionist. We conducted a tour of the practice and looked at the storage arrangements for emergency medicines and equipment. We reviewed the practice’s decontamination procedures of dental instruments and also observed staff interacting with patients in the waiting area.
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
26 October 2016
We carried out an announced comprehensive inspection on 21 September 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
Hampden Dental Clinic is located in the London Borough of Barnet and provides both NHS and private dental treatment to both adults and children. The premises are on the ground floor and consist of a two treatment rooms, a reception area and a dedicated decontamination room. The practice is open Monday and Thursday 9:00am – 5:00pm, Tuesday and Wednesday 9:00 – 7:00pm and Friday 9:00am – 1:00pm.
The staff consists of the principal dentist, two associate dentists, two dental nurses and a receptionist.
The principal dentist is the registered manager. A registered manager is a person who is registered with the Care Quality Commission 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.
The principal dentist had recently become the registered manager at the practice. The principal dentist told us they had undertaken a full assessment of the practice to identify deficiencies. Following this assessment an action plan had been formulated to ensure the practice had improved clinical governance systems in place.
We reviewed 36 CQC comment cards and the NHS Friends and Family test. Patients who had provided the feedback were positive about the service. They were complimentary about the friendly and caring attitude of the staff.
The inspection took place over one day and was carried out by a CQC inspector and a dental specialist advisor.
Our key findings were:
- Patients’ needs were assessed and care was planned in line with current guidance such as from the National Institute for Health and Care Excellence (NICE).
- We found the dentists regularly assessed each patient’s gum health and took X-rays at appropriate intervals.
- Patients were involved in their care and treatment planning so they could make informed decisions.
- There were effective processes in place to reduce and minimise the risk and spread of infection.
- The practice had effective safeguarding processes in place and staff understood their responsibilities for safeguarding adults and child protection.
- Equipment, such as the autoclave (steriliser), fire extinguishers, and X-ray equipment had all been checked for effectiveness and had been regularly serviced.
- Patients were treated with dignity and respect and confidentiality was maintained.
- The practice had implemented clear procedures for managing comments, concerns or complaints.
- Patients indicated that they found the team to be efficient, professional, caring and reassuring.
- Patients had good access to appointments, including emergency appointments, which were available on the same day.
- Leadership structures were clear and there were processes in place for dissemination of information and feedback to staff.
There were areas where the provider could make improvements and should:
- Review the practice’s protocols for recording in the patients’ dental care records or elsewhere the reason for taking the X-ray and quality of the X-ray giving due regard to the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2000.
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Review the practice’s audit protocols to ensure audits of various aspects of the service, such as radiography and dental care records are undertaken at regular intervals to help improve the quality of service. Practice should also check that where applicable audits have documented learning points and the resulting improvements can be demonstrated.