Goldthorne Clinic

Updated 13 March 2017

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.

This inspection took place on 30 January 2017 and was led by a CQC inspector and supported by a specialist dental advisor. Prior to the inspection, we reviewed information we held about the provider. We informed NHS England area team that we were inspecting the practice and we did not receive any information of concern from them. We asked the practice to send us some information that we reviewed. This included the complaints they had received in the last 12 months, their latest statement of purpose, and the details of their staff members including proof of registration with their professional bodies.

During our inspection we toured the premises; we reviewed policy documents and staff records and spoke with five members of staff. We looked at the storage arrangements for emergency medicines and equipment. We were shown the decontamination procedures for dental instruments and the computer system that supported the dental care records.

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 13 March 2017

We carried out an announced comprehensive inspection on 30 January 2017 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

Goldthorn Dental Practice has five dentists who work part-time (including the principal dentists), a part-time dental therapist, three qualified dental nurses who are registered with the General Dental Council (GDC), two trainee dental nurses and a receptionist (who is also a registered dental nurse). The practice’s opening hours are 9am to 5pm on Monday to Friday.

Goldthorn Dental Practice provides mainly NHS dental treatments to patients of all ages but also offers private treatment options. The practice has two dental treatment rooms on the ground floor and two on the first floor. Sterilisation and packing of dental instruments takes place in two separate decontamination rooms; one on the ground and one on the first floor. There is a reception with adjoining waiting area on the ground floor and a separate reception and waiting area on the first floor.

Before the inspection we sent Care Quality Commission comments cards to the practice for patients to complete to tell us about their experience of the practice. We received comments from 29 patients by way of these comment cards.

Our key findings were

• Systems were in place for the recording and learning from significant events and accidents although records seen were not always fully completed.
• There were sufficient numbers of suitably qualified staff to meet the needs of patients.
• Patients were treated with dignity and respect.
• The practice was visibly clean and well maintained.
• Infection control procedures were in place and staff had access to personal protective equipment such as gloves and aprons.
• There was appropriate equipment for staff to undertake their duties, although autoclaves used in the decontamination process were overdue for their annual service.
• Oral health advice and treatment were provided in-line with the ‘Delivering Better Oral Health’ toolkit (DBOH).
• Staff had been trained to deal with medical emergencies and the provider had emergency equipment in line with the Resuscitation Council (UK) guidelines. However staff were not recording checks made on the automated external defibrillator to demonstrate that it was available for use in good working order. We were told that these checks would be implemented immediately.
• Local rules were available in all of the treatment rooms where X-ray machines were located and records were available to demonstrate that testing of X-ray equipment had been completed as required.
• The appointment system met the needs of patients and waiting times were kept to a minimum.
• Governance systems were in place although some shortfalls were identified during this inspection. For example not all actions identified in the fire risk assessment had been addressed and although the practice had policies in place not all were dated or contained a date of review so the practice were unable to demonstrate that these contained the most up to date information.
• Staff told us that there were clearly defined leadership roles within the practice they felt supported, involved and they all worked as a team.

There were areas where the provider could make improvements and should

• Review the systems in place for the recording, investigating and reviewing of accidents or significant events.
• Review systems in place for the undertaking of regular servicing and maintenance of equipment used in decontamination procedures and provision of up to date service level agreements regarding this equipment.
• Review the practice’s systems for assessment of risk, providing  evidence of  action taken to identify any risks identified. For example the fire risk assessment.
• Review systems to ensure that patient care records kept during domiciliary visits record the required information including patients’ medical history; consent and ensuring that treatment plans were available.
• Review the practice’s protocols for recording in the patients’ dental care records or elsewhere the reason for taking the X-ray giving due regard to the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2000.
• Review the practice’s responsibilities to the needs of people with a disability and the requirements of the Equality Act 2010 and ensure an access audit is undertaken for the premises.
• Review audit protocols to document learning points that are shared with all relevant staff and ensure that the resulting improvements can be demonstrated as part of the audit process.
• Review the systems in place for review of policies and procedures and provide evidence that those available at the practice are kept under regular review.