• Dentist
  • Dentist

Archived: Irby Dental Surgery

67 Thingwall Road, Irby, Wirral, Merseyside, CH61 3UB (0151) 648 1974

Provided and run by:
Sharma Family Ltd

All Inspections

08/08/2018

During an inspection looking at part of the service

We undertook a follow up focused inspection of Irby Dental Surgery on 8 August 2018. This inspection was carried out to review in detail the actions taken by the provider to improve the quality of care, and to confirm that the practice was now meeting the legal requirements.

The inspection was led by a CQC inspector who was supported by a specialist dental adviser.

We undertook a comprehensive inspection of Irby Dental Surgery on 11 April 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We found the 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 Irby Dental Surgery on our website www.cqc.org.uk.

When one or more of the five questions are not met we require the provider to make improvements. We then inspect again after a reasonable interval, focusing on the areas in which improvement was necessary.

As part of this inspection we asked:

• Is it well-led?

Our findings were:

Are services well-led?

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

The provider had made sufficient improvements in relation to the regulatory breach we identified at our inspection on 11 April 2018.

Background

Irby Dental Surgery is near the centre of Irby and provides private dental care and treatment for adults and children.

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

The dental team includes two dentists, two dental hygiene therapists and three dental nurses, one of whom is the practice manager. 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 Irby Dental Surgery is the principal dentist.

During the inspection we spoke with the principal dentist, a dental nurse, 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 Friday 9.00am to 5.30pm.

Our key findings were:

  • The provider had improved their systems and processes to enable them to assess, monitor and improve the quality and safety of the services being provided, for example, we saw infection control systems were now operating more effectively.

  • We saw that the provider’s systems and processes for enabling them to identify and reduce risks at the practice were now operating more effectively, for example, in relation to the control of the practice’s water systems.

  • The provider had improved systems and processes to enable them to evaluate and improve their practice and had put further arrangements in place to encourage patients to provide feedback.

  • We found that the system for monitoring staff training had improved but was not operating effectively.

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

  • Review the practice's protocols and procedures to ensure staff are up to date with their training and continuing professional development.

  • Review the practice’s protocols to ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.

11/04/2018

During a routine inspection

We carried out this announced inspection on 11 April 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 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 not providing well-led care in accordance with the relevant regulations.

Background

Irby Dental Surgery is near the centre of Irby and provides private dental care and treatment for patients of all ages.

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

The dental team includes two dentists, two dental hygiene therapists and three dental nurses, one of whom is the practice manager. 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 Irby Dental Surgery was the principal dentist.

We received feedback from twelve people during the inspection about the services provided. The feedback provided was positive about the practice.

During the inspection we spoke to the two dentists, dental nurses 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 Friday 9.00am to 5.30pm.

Our key findings were:

  • The practice was clean and well maintained.
  • Staff knew how to deal with medical emergencies. Appropriate medicines and equipment were available.
  • The provider had staff recruitment procedures in place.
  • 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 dental team provided preventive care and supported patients to achieve better oral health.
  • The appointment system took account of patients’ needs.
  • The practice had a leadership and management structure in place.
  • Staff felt involved and supported.
  • The provider had information governance arrangements in place.
  • The practice had infection control procedures in place. These did not always reflect published guidance.
  • The provider had systems in place to manage risk. We found that systems relating to the control of hazardous substances, staff vaccination and the control of Legionella were not operating effectively.
  • The provider had safeguarding procedures in place and staff knew their responsibilities for safeguarding adults and children. We saw that the safeguarding procedures were not practice specific.
  • We saw that the provider’s complaints procedure did not contain sufficient information.
  • The provider had limited arrangements in place to seek the views of patients about the services they provided.

We identified regulations the provider was not meeting. They must:

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

Full details of the regulations the provider was not meeting are at the end of this report.

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

  • Review the practice's policies and procedures for obtaining patient consent to care and treatment to ensure they are in compliance with legislation, take into account relevant guidance, and staff follow them.
  • Review the practice's complaint handling procedures and establish an accessible system for identifying, receiving, recording, handling and responding to complaints by service users. This did not include information about the Dental Complaints Service.
  • 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.

6 December 2016

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Irby Dental Practice on 9 February 2016 and at this time breaches of legal requirements were found. After the comprehensive inspection the practice wrote to us and told us that they would take action to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment

Regulation 17 HSCA (RA) Regulations 2014 Good governance

On 6 December 2016 we carried out a follow up inspection of this service under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was carried out to check whether the provider had completed the improvements needed and identified during the comprehensive inspection in February 2016.

We reviewed the practice against two of the five questions we ask about services: is the service safe and well-led? This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Irby Dental Practice on our website at www.cqc.org.uk

We revisited Irby dental practice as part of this review and checked whether they had followed their action plan and to confirm that they now met the legal requirements.

Our findings were:

Are services safe?

We found that this practice was providing safe 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

The practice is situated in Irby village, Wirral. The practice has two dentists, two dental hygienist/therapists, two qualified dental nurses, and a practice manager. The practice provides primary dental services to private patients only.

The practice is open:

Monday to Thursday 9am – 5pm

Friday 9am – 4pm

One of the principal dentists 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.

Our key findings were:

We found that this practice was now providing safe and well led care in accordance with the relevant regulations.

  • Fire safety training and fire drills had been undertaken by all staff.
  • A system was in place to receive, act on and document patient safety alerts where relevant and applicable.
  • Infection control policies and procedures were in place and reflected national guidance.
  • An infection control audit had recently been undertaken.
  • The dentists undertook self-audits of their radiographs monthly. They also recorded justification of X-rays in patients’ records.
  • Patient feedback was invited by means of a comment book available at reception which was monitored and patient satisfaction surveys were undertaken every three years by an external company.

We found that the practice had acted upon other recommendations made at the previous inspection to improve the service and care. For example:

  • The practice’s protocols and procedures for promoting the maintenance of good oral health had been reviewed giving due regard to guidelines issued by the Department of Health publication ‘Delivering better oral health: an evidence-based toolkit for prevention’.
  • The practice’s sharps procedures had been reviewed giving due regard to the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013
  • The recruitment process had been reviewed. We saw evidence that a new member of staff had relevant information held on file relating to their employment except for an appropriate DBS check. Evidence submitted following the inspection demonstrated that an appropriate DBS check had been applied for and the practice were waiting its return.
  • A business continuity and disaster recovery plan had been implemented.
  • An additional dental nurse had been employed to improve nurse cover in times of staff absence.
  • One of the dental nurses was also qualified as a first aider to give first aid treatment in the event of an injury or illness.
  • A practice information leaflet had been implemented.

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

  • Review their audit programme to include relevant audits in order to demonstrate quality improvement.
  • Review their recruitment policy to include obtaining a relevant disclosure and barring (DBS) check prior to employment.
  • Review their arrangements to ensure shared learning and feedback is regularly discussed in relation to; patient feedback, audits, health and safety issues and updates to clinical practice.

9 February 2016

During a routine inspection

We carried out an announced comprehensive inspection on 9 February 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 not 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 not providing well-led care in accordance with the relevant regulations.

Background

The practice is situated in Irby village, Wirral. The practice has two dentists, two dental hygienist/therapists, two qualified dental nurses, one of which acts as a receptionist and practice manager also. The practice provides primary dental services to private patients only. The practice is open:

Monday, Tuesday, Thursday 8.30am – 5pm

Wednesday 9am - 5pm

Friday 8.30am – 4pm

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.

We received feedback from 25 patients about the service. The 23 CQC comment cards seen and two patients spoken to reflected positive comments about the staff and the services provided. Patients commented that the practice appeared clean and tidy and they found the staff very caring, friendly and professional. They had trust and confidence in the dental treatments and said explanations from clinical staff were clear and understandable. Urgent or emergency appointments were available within 48 hours and appointments usually ran on time.

Our key findings were:

  • The practice recorded and analysed accidents and complaints and would cascade learning to staff when they occurred. However there had been no recorded complaints or significant events recorded in the last 12 months.
  • Staff had received safeguarding training and knew the process to follow to raise any concerns.
  • There was a limited number of suitably qualified staff to meet the needs of patients.
  • Staff had been trained to deal with medical emergencies, however emergency medicines and emergency equipment was not suitable.
  • Improvements were needed to infection prevention and control procedures.
  • Patients received explanations about their proposed treatment, costs, benefits and risks and were involved in making decisions about it.
  • Patients were treated with dignity and respect and their confidentiality was maintained.
  • The appointment system met the needs of patients and waiting times were kept to a minimum.
  • The practice staff worked as a team; however they lacked support for undertaking their roles and with professional development.
  • The practice took into account any patient comments and used these to help them improve, however no formal system for obtaining feedback from patients was in place.
  • The practice did not have a structured plan in place to audit quality and safety of services provided. The policies and procedures were not localised to the practice or updated in line with current legislation and guidance.

We identified regulations that were not being met and the provider must:

  • Ensure fire safety training, fire risk assessments and regular fire drills take place.
  • Ensure they comply with relevant patient safety alerts and recall notices issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and through the Central Alerting System (CAS).
  • Ensure infection prevention and control policies and procedures are implemented that follow the Department of Health’s Code of practice about infection prevention and control of healthcare associated infections (Health and Social care Act 2008: Code of practice for health and adult social care on the prevention and control of infections and related guidance) and the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices (HTM 01-05)
  • Ensure audits of various aspects of the service, such as radiography, infection control and dental care records are undertaken at regular intervals to help improve the quality of the service. The practice should also ensure all audits have documented learning points and the resulting improvements can be demonstrated.
  • Ensure a system is implemented by which patient views are obtained and analysed and used to help improve services.
  • Ensure that their audit and governance systems are implemented and remain effective.

You can see full details of the regulations not being met at the end of this report.

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

  • Reviewing the practice’s protocols and procedures for promoting the maintenance of good oral health giving due regard to guidelines issued by the Department of Health publication ‘Delivering better oral health: an evidence-based toolkit for prevention’.
  • Assessing the risks to patients and implementing preventative measures when undertaking root canal treatment giving due regard to guidelines issued by the British Endodontic Society.
  • Reviewing at appropriate intervals the training, learning and development needs of individual staff members and establish an effective process for the on-going assessment, supervision, training and development of all staff.
  • Reviewing the practice’s sharps procedures giving due regard to the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013
  • Reviewing 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.
  • Reviewing the practice's recruitment policy and procedures to ensure appropriate Disclosure and Barring Service (DBS) checks, character references for new staff and proof of identification are requested and recorded suitably and maintain accurate, complete and detailed records relating to employment of staff.
  • Implementation of a paper records storage system that meets health and safety and fire regulations in accordance with the Department of Health’s code of practice for records management (NHS Code of Practice 2006) and other relevant guidance about information security and governance.
  • Implementation of a comprehensive business continuity plan and make it readily available to all staff.
  • Reviewing staffing requirements to ensure adequate numbers of suitably qualified and skilled staff work at the practice to meet the needs of patients and ensure suitable cover is available in times of staff absence.
  • Reviewing the need for suitably trained first aiders to be present at all times during the practice open hours.
  • Reviewing the support mechanisms for staff to ensure they are supported professionally and in training and development and are able to access supervision and support for their role.
  • Publishing a practice information leaflet to inform patients of the services offered, costs, staffing and the complaints procedure. Publicise information for patients on how to access emergency dental care out of normal practice working hours.

16 November 2012

During a routine inspection

Irby Dental Practice had a guide to services for new and existing patients available on the website; this provided comprehensive information about what services were offered at the practice.

We found from patients and their records that people receiving treatment were informed as to the options and course of treatment needed, we found from records that oral hygiene advice and dental decay prevention advice had been given to children. We saw evidence that treatment costs were explained and consent was obtained in all cases before treatment commenced. All staff working in the practice had relevant criminal record bureau disclosure checks (CRB’s). The registered manager Mr Sharma had attended safeguarding training and all other staff were booked to attend training in January 2013. During our visit we found the practice had thorough hygiene practices and quality auditing. Staff told us they had worked at the practice for a long time and they enjoyed working at Irby Dental Practice.