Updated 3 October 2019
We carried out this announced inspection on 2 September 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
Broadway Lifemiles is in Thatcham and provides private treatment to adults and children.
The practice is based on the first floor and is not accessible to patients who find the stairs a barrier. Staff advise potential new patients of this when they contact the practice.
The dental team includes two dentists, two dental nurses, one dental hygienist, one dental hygiene therapist and a patient experience manager.
The practice has three treatment rooms.
The practice is owned by an individual who is the principal dentist. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.
On the day of inspection, we collected 45 CQC comment cards filled in by patients and obtained the views of two other patients.
During the inspection we spoke with the principal dentist, one dental nurse and the business development manager.
We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
- Monday to Friday 8am – 5pm
Our key findings were:
- 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, but improvements were needed to the fire, electrical safety arrangements and infection prevention risks.
- The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The provider had staff recruitment procedures.
- 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 supported patients to ensure better oral health.
- The appointment system took account of patients’ needs.
- Staff felt involved and supported and worked well as a team.
- 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:
- Improve the practice's systems for assessing, monitoring and mitigating the various risks arising from the undertaking of the regulated activities. In particular the five yearly electrical installation check and the effectiveness of the fire risk assessment.
- Implement audits for prescribed antibiotic medicines for taking into account the guidance provided by the Faculty of General Dental Practice.
- Take action to ensure the availability of an interpreter service for patients who do not speak English as their first language.
- Take action to ensure audits of patient care records have documented learning points and where appropriate, resulting improvements can be demonstrated.