Updated 3 August 2018
We carried out this announced inspection on 12 July 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 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 had remote access to 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
West Park Practice is in Brighouse and provides NHS and private treatment to adults and children. They provide dental implants and treatment under conscious sedation.
There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice.
The dental team includes four dentists, four dental nurses, one dental hygienist, one dental hygiene therapist, two receptionists and a practice manager. The practice has four 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 West Park Practice is the practice manager.
On the day of inspection, we collected 14 CQC comment cards filled in by patients.
During the inspection we spoke with one dentist, two dental nurses, the dental hygienist, one receptionist 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 from 8:00am to 5:15pm
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 practice had systems to help them manage risk to patients and staff. Improvements could be made to the processes for reducing the risks associated with Legionella.
- Improvements could be made to the process for managing the Cone Beam CT (CBCT) machine.
- The practice staff 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.
- The provider was providing preventive care and supporting patients to ensure better oral health.
- The appointment system met patients’ needs.
- The practice had effective leadership and culture of continuous improvement.
- The practice asked 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 and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account HPA-CRCE-010 Guidance on the Safe Use of Dental Cone Beam (Computed Tomography).
- Review the practice's Legionella risk assessment and ensure water temperatures do not fall below the temperature recommended in the risk assessment.