19 June 2019
During a routine inspection
We carried out this announced inspection on 19 June 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
Citrine House - Borough Road Wakefield provides NHS and private treatment to adults and children. The practice is an approved foundation dentist training practice. Foundation training practices have been approved by the dental deanery to provide training and support to newly qualified dentists. They are also part of a pilot project to provide training to newly qualified dental hygiene therapists.
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 10 dentists (two of who are foundation dentists), 14 dental nurses (two of whom are trainees), an instrument decontamination nurse, three dental hygienists, one foundation dental hygiene therapist, three receptionists and a practice manager. The practice has seven treatment rooms.
The practice is owned by an individual who is the principal dentist there. 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 15 CQC comment cards filled in by patients.
During the inspection we spoke with four dentists, three dental nurses, one dental hygiene therapist, two receptionists 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 Thursday from 8:00am to 6:20pm
Friday from 8:00am to 4:20pm
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.
- The practice had systems to help them manage risk to patients and staff.
- The provider 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.
- Staff were providing preventive care and supporting patients to ensure better oral health.
- The appointment system took account of patients’ needs.
- The provider had effective leadership and culture of continuous improvement. Audit was well used within the service to continually drive improvement in quality, safety and patient experience.
- Staff felt involved and supported and worked well as a team. Meeting structures had been developed to enable all staff to have an equal voice and raise concerns or ideas without fear of recrimination.
- The provider asked patients for feedback about the services they provided. They had developed a patient participation group.
- 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 for managing and the following up of sharps injuries.