Updated 18 September 2019
We carried out this announced inspection on 6 August 2019 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
Treetops (Midlands) Limited is in Codsall and provides NHS and private treatment to adults and children. The practice is part of a group of 10 practices which are owned by different providers.
There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces, including two spaces for blue badge holders, are available near the practice.
The dental team includes ten dentists, one with a special interest in endodontics, one with a special interest in orthodontics and one being a periodontist. Supporting the dentists are eight dental nurses including three trainee dental nurses and the clinical lead nurse, three dental hygienists, two dental hygiene therapists, two receptionists one of whom is the reception manager, a laboratory technician, a visiting sedationist, two administrators and the company director who owns the practice. The practice has nine 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 Treetops (Midlands) Limited is the director.
On the day of inspection, we collected 12 CQC comment cards filled in by patients and spoke with three patients.
During the inspection we spoke with five dentists, six dental nurses including two trainee dental nurses and the clinical lead nurse, the reception manager, the laboratory technician and the company director. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday, Tuesday, Wednesday and Friday from 8am to 5.30pm.
Thursday from 8am to 6pm.
Saturday by appointment only with the periodontist.
Our key findings were:
- Strong and effective leadership was provided by the company director and management team. Staff felt involved and supported and informed us this was a good place to work.
- The practice appeared clean and well maintained.
- The provider had infection control procedures which reflected published guidance.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- The provider had systems to help them manage risk to patients and staff.
- The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The provider 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.
- Staff provided preventive care and supporting patients to ensure better oral health. They routinely referred patients to their dental hygienists and dental hygiene therapists through a clear care pathway.
- The appointment system took account of patients’ needs. There were various specialists and dentists with special interests which enhanced services provided within the practice. Specialisms included periodontics, endodontics, dental implants and orthodontics.
- The provider had effective leadership and culture of continuous improvement.
- The provider asked staff and patients for feedback about the services they provided.
- The provider dealt with complaints positively and efficiently.
- The provider had suitable information governance arrangements.
There were areas where the provider could make improvements. They should:
- Review the practice’s protocols for ensuring that all clinical staff have adequate immunity for vaccine preventable infectious diseases.
- Review the practice's policy for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken for all products.