We carried out an announced inspection of this practice on 18 September 2015. Breaches of legal requirements were found. After the inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to good governance.

We undertook this focused inspection to check they had followed their plan and to confirm they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Eden Villas Dental Practice on our website at www.cqc.org.uk

Our findings were:

Are services well-led?

We found that this practice was providing well-led care in accordance with the relevant regulations.

Background

Eden Villas Dental Practice is situated in Washington, Tyne and Wear. The surgery provides a comprehensive range of NHS dental services including preventative advice and routine restorative dental care.

The practice is open:

Monday to Wednesday 9am to 6pm

Thursday 9am to 1pm

Friday 9am to 4.30pm

Our key findings were:

• The practice had reviewed their protocol for completing dental care records giving due regard to guidance provided by the Faculty of General Dental Practice in respect of clinical examinations and record keeping.
• The practice had completed audits including x-ray, infection prevention and control and clinical record keeping. All audits had a documented action plan with guidance on how the practice would implement the improvements.

We carried out an announced comprehensive inspection on 18 September 2015 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 not providing well-led care in accordance with the relevant regulations.

Background

The practice is a partnership. The practice provides primary care dental services under the NHS.

The practice is open:

Monday to Wednesday 9am to 6pm

Thursday 9am to 1pm

Friday 9am to 4.30pm

There are two dentists, five dental nurses and one receptionist/practice manager.at the practice.

The owner of the practice is the registered provider for the practice. 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.

We also received 55 Care Quality Comment cards. All the comments were positive about the staff and the services provided. Comments included: the practice was safe and hygienic; staff were very approachable and excellent treatment.

Our key findings were:

• There was a complaints system in place. Staff recorded complaints and cascaded learning to staff.
• Staff had received safeguarding training, knew how to recognise signs of abuse and how to report it.
• There were sufficient numbers of suitably qualified staff to meet the needs of patients.
• Staff had been trained to manage medical emergencies.
• Infection control procedures were in accordance with the published guidelines.
• Patient care and treatment was planned and delivered in line with evidence based guidelines, best practice and current regulations.
• Patients received clear explanations about their proposed treatment, costs, benefits and risks and were involved in making decisions about it, although this was not always recorded.
• Patients were treated with dignity and respect and confidentiality was maintained.
• The appointment system met patients’ needs.
• The governance systems were effective.
• The practice sought feedback from staff and patients about the services they provided.

We identified regulations that were not being met and the provider must:

• Review the practice's protocols for completing dental care records giving due regard to guidance provided by the Faculty of General Dental Practice in respect of clinical examinations and record keeping.
• Ensure all audits have a documented action plan with guidance on improvements required and timescales for review.

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

• Review the practice’s protocols for the use of rubber dam for root canal treatment giving due regard to guidelines issued by the British Endodontic Society.
• Record information in the patient care records about preventative advice given in line with the ‘Delivering Better Oral Health’ (DBOH) toolkit. – an evidence based tool kit used by dental teams for the prevention of dental disease in a primary and secondary care setting.
• Review the practice’s protocols for recording in the patients’ dental care records or elsewhere the reason for taking the-X-rays and reporting on the X-rays giving due regard to the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2000.

Surveys carried out showed people that used the practice were happy with the service provided. They felt they were given enough information about their treatment options and the relevant fees and were able to ask all the questions they wanted to.They found the staff to be friendly and reported that they were treated with respect and their privacy was maintained.