We carried out an announced comprehensive inspection on 8 March 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 not providing well-led care in accordance with the relevant regulations.
Background
Clifton Garden Dental Surgery is situated in Goole, Humberside. It offers mainly NHS treatment to patients of all ages but also offers private dental treatments. The services include preventative advice and treatment and routine restorative dental care. They also have a contract for the provision of minor oral surgery on a referral basis.
The practice has two surgeries, a decontamination room, one waiting area and a reception area. The reception area, waiting area and both surgeries are on the ground floor. The decontamination room is on the first floor. The toilet facilities were on the first floor of the premises.
There were two dentists, two dental nurses (one of which was on maternity leave) and a practice manager who also covered reception duties. The practice owner was also a qualified dental nurse and would assist when required.
The opening hours are Monday to Thursday from 9-00am to 5-30pm and Friday from 9-00am to 4-30pm.
The practice owner is registered with the Care Quality Commission (CQC) as an individual. 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.
During the inspection we received feedback from 46 patients. The patients were positive about the care and treatment they received at the practice. Comments included that the staff were respectful and courteous. They also commented that the environment was clean and hygienic and that they were listened to.
Our key findings were:
- The surgeries appeared clean and hygienic.
- The practice wase not recording water temperatures on a monthly basis or running infrequently used taps on a weekly basis following recommendations from their Legionella risk assessment.
- The dentists were qualified and staff had received training appropriate to their roles.
- Patients were involved in making decisions about their treatment and were given clear explanations about their proposed treatment including costs, benefits and risks.
- Oral health advice and treatment were provided in-line with the ‘Delivering Better Oral Health’ toolkit (DBOH).
- We observed that patients were treated with kindness and respect by staff. Staff ensured there was sufficient time to explain fully the care and treatment they were providing in a way patients understood.
- Patients were able to make routine and emergency appointments when needed.
- The practice had a complaints system in place and there was an openness and transparency in how these were dealt with.
We identified regulations that were not being met and the provider must:
- Ensure audit protocols to document learning points are shared with all relevant staff and ensure that the resulting improvements can be demonstrated as part of the audit process.
- Ensure an effective system is established to monitor and mitigate the various risks arising from undertaking of the regulated activities.
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:
- Review the practice’s procedure for automatic control test giving due regard to guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices.
- Review the practice’s protocol for the frequency of checks on the emergency drugs.
- Review the availability of a handwashing sink in the staff toilet.
- Display only this practice’s sharps injury procedure display and ensure it contains local contact details for occupational health.
- Review the training, learning and development needs of individual staff members and have an effective process established for the on-going assessment and supervision of all staff.
- Review the storage of dental care records to ensure they are stored securely.
- Review the practice’s business continuity plan to include details of what the practice would do in the event of not being able to see patients.