Acocks Green Dental Practice

Updated 26 May 2016

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 8 February 2016 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; however 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 six members of staff, including the principal dentist. 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 patient treatment 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 26 May 2016

We carried out an announced comprehensive inspection on 8 February 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 providing well-led care in accordance with the relevant regulations.

Background

Acocks Green Dental Practice has three dentists, who work fulltime and a trainee dentist who works part time, six qualified dental nurses who are registered with the General Dental Council (GDC) and a dental hygienist. The practice’s opening hours are 9am to 5pm Monday to Thursday and 9am to 3pm on Friday. The practice is also open for pre-booked appointments only between the hours of 5pm to 7pm on a Monday evening and also on some Saturday mornings.

Acocks Green Dental Practice provides NHS and private treatment for adults and children. The practice is situated in a converted property. The practice has five dental treatment rooms; one on the ground floor and four on the first floor and a separate decontamination room for cleaning, sterilising and packing dental instruments. There is also a reception and waiting area.

The principal dentist 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.

Before the inspection we sent Care Quality Commission comment cards to the practice for patients to complete to tell us about their experience of the practice. We collected 20 completed cards and spoke to eight patients. These provided a positive view of the services the practice provides. All of the patients commented that the quality of care was very good.

We carried out an announced comprehensive inspection on 8 February 2016 as part of our planned inspection of all dental practices. The inspection took place over one day and was carried out by a lead inspector and a dental specialist adviser.

Our key findings were:

• Systems were in place for recording accidents and adverse incidents at the practice.
• There were sufficient numbers of suitably qualified staff to meet the needs of patients.
• The practice was visibly clean and well maintained
• The practice met the essential standards in infection control as set out in the ‘Health Technical Memorandum 01-05 (HTM 01-05): Decontamination in primary care dental practices.’ Published by the Department of Health.
• There was appropriate equipment for staff to undertake their duties, and equipment was well maintained
• Emergency medicines were available in line with the British National Formulary (BNF) guidance for medical emergencies in dental practice.
• Patients were treated with dignity and respect.
• The dentist provided dentistry in accordance with current guidance.
• Patients received clear explanations about their proposed treatment, costs, benefits and risks and were involved in making decisions about it.
• Staff were observed to be friendly, caring and professional
• The appointment system met the needs of the patients and waiting times were kept to a minimum.
• Staff we spoke with felt well supported by the management team and were committed to providing a quality service to their patients.

There were areas where the provider could make improvements and should:

• Review accident reporting procedures to ensure information is recorded including details of advice given or follow up action taken.
• Review the practice’s procedures for training in cardiopulmonary resuscitation to ensure staff receive simulation training as detailed in the quality standards for cardiopulmonary resuscitation practice and training produced by the resuscitation council (UK).
• Review the protocols and procedures to ensure staff are up to date with their mandatory training and their Continuing Professional Development.
• Review the practice’s audit protocols of various aspects of the service, such as infection prevention and control, radiography and dental care records at regular intervals to help improve the quality of service. Review its 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 procedure for completion of soil and protein tests on the ultra-sonic cleaner to ensure they are completed in line with HTM 01-05 recommendations.