Below is a report following a recent CQC inspection from a practice manager within the Alpha group that Ian Gordon has kindly allowed to share. Hopefully this will be of benefit to those not already been through the process!
We were inspected on 4 outcomes today. They where Outcome 2 Consent , Outcome 4 General care & welfare of people that use the services. Outcome 7 Safeguarding and Outcome 8 Cleanliness and Infection control
Out come 2 – consent
They looked at patient records , did speak to them on confidentiality and they explained that they would speak to the patients attending today. Reception explained to patients on arrival that we were being inspected and would they object.
The patient feedback was very positive , they patients mentioned how friendly and helpful the staff where. The fact that we always rang the patinets to remind them about their appointments. Also they were given a treatment plan ( or as it was described a letter with teeth on it )
The dentist was lovely always helpful and explained everything and understanding that sometimes they didnt wish to know all the ins and out pf the treatment.
We met this outcome fully and no concerns at all where raised .
They looked at PR forms for signatures and dates but only todays. It was explained that MH were updated regularly too.
Outcome 4 – good evidence met requirements no concerns
They thought the Patient information folder was excellent had an awful lot of detail in and was extremely helpful. They mentioned the fact we had patients comments in from questionnaires. I explained that we had started a different type of questionnaire now and this was a more directed to specific areas.
These they looked at also the old PSQs .
Asked about complaints – Leyburn havent had any , but they are really only looking at ones since registration. How did we deal with them if this was the case . Explained the process. But it had been noted that the Complaint policy was in folder for the patient to read.
Training was upto date for staff. They asked questions on CRB checks plus did they receive training in areas of infection control on starting .
Of course and it was an ongoing process. Also looked at qualification certificates for staff plus various others certificates. Informed them that we try to encourage staff to do training on line through CPD4dentalnurses and we paid for the subscription annually.
CRB asked if all staff had them . Asked Bev date of starting and had she had one . ( I queried this later and this is because CRBs are not transferable between companies, so we need to check that we do do them for all new starters and for those that have a CRB from a different practice) They took the number of Bevs CRB and also her GDC number. So they can check .
They looked at Staff meetings minutes asking how often . Explained about the other meeting PM one Partners and peer reviews. Also nurses forum. Told them about discussion of any change in policy/ protocols would be discussed. Also we had a part set agenda that would be discussed. Staff where asked for there input. Also to add to agenda if they wanted to discuss anything
They did ask about controlled drugs on the premises ( this was more out of interest than any of the outcomes ) Explained what procedure we had in place for the drugs O2 and the AED.
Audits
They covered wanted to know what audits we had done – again showed them ( luckily had taken laptop) had them all on this . Also showed the infection control audit the PCT sending in ( yesterday )
Asked how often we would do this – every 3 months
Where surprised that we had Radiology policy and didnt realise that we took x-rays . Dont know which dentist they go to!
Looked at H&S, Sharps COSSH, Infection control & decontamination Transportation of instruments and waste policies
Outcome 7
Safeguarding Children and Vunerable adults .
Certificates looked at for this . Explained that it had been difficult finding the courses for both of these as NYY where not forth coming in putting these courses on. Most staff had done them through e-learning. This was exceptable.
Asked about Mental law had dentists done this
We lacked a Safeguarding Vunerable Adults policy but happy we would deal with this as soon as possible. Need to ensure that we get the right phone numbers for this as we have with the children. But adults must have a Police number with these.
It would be good practice for all staff to do the mental law if possible – this would be done through Kwango as the adults course. ( No rush but as I said good practice)
Out come 8
Infection control – they siad we had good evidence on this
Looked at our check sheets and thought they were thorough. Asked Bev to talk them through the decontamination routine . That was ok no problems . Didnt mention soap dispensers one or two sinks . Happy it flowed from clean to dirty (left to right)
They also asked about maintenance of equipment, did we keep a log of equipment repairs etc .
As I said before it went very well and we are compliant.
They did say they would make a note of this so the person inspecting would know that it could only be a Friday. But this probably wouldnt be until after March 31st. They have only so many they need to do before that date. But could say more.
I hope this is not to much of a ramble ( probably is ) But to have two people asking you questions at the same time was quite intense as they leapt from one item to another.
All the outcomes over lap by the way this is why this seems chaotic.
They send a report and we can agree or disagree with them, this is given a 10 day period once all this is complete it will be published after that
I thought it might be an idea to hold a PM meeting to go through all this asap ?? What do you think ?