Updated 1 November 2017
We carried out this announced inspection on 22 September 2017 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
Station Road Dental Practice is in Hinckley, a market town in southwest Leicestershire and provides NHS and private treatment to patients of all ages. There are currently over 51,000 patients registered.
The practice is well established within the town and has been providing dental care for patients for approximately 100 years. The provider told us that the partnership was in the process of purchasing the building as it is currently leased.
There are steps at the front of the practice to gain entry into the premises. The practice has a bell and portable ramp which ensures ease of access for those who use wheelchairs and pushchairs. There are some limited car parking spaces at the front of the premises. Public car parking is also available near to the practice.
The dental team includes eight dentists (four of these are partners), 13 dental nurses, three dental nurse apprentices, five dental hygienists/therapists and four receptionists. The practice has 11 treatment rooms; three of these are on the ground floor.
The practice is owned by a partnership 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 Station Road Dental Practice is one of the partners.
On the day of inspection we collected 28 CQC comment cards filled in by patients. This information gave us a positive view of the practice.
During the inspection we spoke with two dentists, three dental nurses, a receptionist and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday to Thursday from 8.30am to 6.30pm and Friday from 8.30am to 5.30pm.
Our key findings were:
- The practice ethos was to deliver a high standard of dental treatment in a caring, safe and thoughtful environment. The practice objectives included raising awareness of prevention and positive health choices to its patients.
- Effective leadership was evident in most areas of the practice. We noted areas where management arrangements could be strengthened.
- Staff had been trained to deal with emergencies and equipment and appropriate medicines were readily available in accordance with current guidelines.
- The practice appeared clean and well maintained.
- The practice had infection control procedures which reflected current published guidance.
- Staff demonstrated awareness of their responsibilities for safeguarding adults and children living in vulnerable circumstances. We identified that some staff training records were dated in 2012 and not all staff could evidence they had received training.
- The practice had adopted processes for the reporting of significant events. We found that systems required strengthening to ensure that all incidents were reported, investigated and that staff learning from incidents were recorded.
- Clinical staff provided dental care in accordance with current professional and National Institute for Care Excellence (NICE) guidelines.
- The practice demonstrated awareness of the needs of the local population and took these into account when delivering the service.
- Patients had access to routine treatment and urgent care when required.
- Staff received most training appropriate to their roles and were supported in their continued professional development (CPD) by the practice. The practice had not adopted a monitoring system to ensure all staff training was up to date.
- The practice dealt with complaints positively and efficiently.
- Staff we spoke with felt committed to providing a quality service to their patients.
There were areas where the provider could make improvements. They should:
- Review the practice’s sharps procedures and ensure the practice is in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
- Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.
- Review its responsibilities to the needs of people with a disability, including those with hearing difficulties and the requirements of the Equality Act 2010.
- Review the use of risk assessments to monitor and mitigate the various risks arising from undertaking of the regulated activities.