We carried out an announced comprehensive inspection on 1 November 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

West End Manse Dental Surgery provides primarily NHS treatment to adults and children and serves about 18000 patients. The team consists of five dentists, 11 part-time dental nurses, a receptionist and administrator.

The practice is situated in a converted residential property and has five dental treatment rooms and a decontamination room for sterilising dental instruments. There is a waiting area, a reception area, office and staff room.

The practice is open from 8.45am to 6pm on Mondays and Fridays and from 8.45am to 5.15pm on Tuesday and Wednesdays. On Fridays it is open from 8.45am to 2pm.

At time of inspection, the principal dentist was 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 comment cards to the practice for patients to complete to tell us about their experience of the practice. We received feedback from 25 patients. These provided a very positive view of the service provided.

Our key findings were:

• Information from 25 completed Care Quality Commission comment cards gave us a positive picture of a friendly, professional and high quality service.

• The practice had good facilities and was well equipped to treat patients and meet their needs.

• The practice had systems to help ensure patient safety. These included safeguarding children and adults from abuse, maintaining the required standards of infection prevention and control, and responding to medical emergencies.

• Risk assessment was robust and action was taken to protect staff and patients.

• There were sufficient numbers of suitably qualified and competent staff. Members of the dental team were up-to-date with their continuing professional development and supported to meet the requirements of their professional registration.

• Patients’ needs were assessed and care was planned and delivered in line with current best practice guidance from the National Institute for Health and Care Excellence (NICE) and other published guidance.

• Staff felt well supported and were committed to providing a quality service to their patients.

• Recommendations form the practice’s legionella assessment had not been implemented to reduce the risk of bacterial growth

• The practice’s recruitment procedures were not robust.

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

• Review the practice’s legionella assessment and ensure that all recommendations are implemented.

• Review the practice's recruitment policy and procedures to ensure references for new staff are obtained.
• Review the security of prescription pads in the practice and ensure there are systems in place to monitor and track their use.

We found that dental care was provided according to people's assessed needs and that people signed consent and treatment records to show that the person understood the treatment provided. The dental staff spoke with people during their consultation prior to any treatment to establish if there were any changes to their medical history. They also ensured that people understood the treatment.

We spoke with five people who had used the service on the day of our visit. All told us that they were happy with the service they received. One person told us, “The dentist is friendly and I would recommend them with no hesitation.”

The service does have a ground floor surgery that can accommodate anyone unable to use the stairs. The practice manager informed us the service operates a later evening service on Monday and Thursday.

We spoke with four staff who told us about how consent for treatment was obtained and medical records were stored and up dated for each treatment on the computer system.

We spoke with four staff, they were all aware from their training of the safeguarding procedure for children and vulnerable adults. There was a complaints procedure in place along with surveys and a suggestion box available in reception. The service supported its staff through training and ensured they had regular appraisals. We found all staff mandatory training was up to date.