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Quality Assurance

Our practice aims to provide dental care of a consistent quality for all patients; we strive to meet the high standards expected in any clinical setting. We expect all members of our dental team to work to these standards to help us achieve our aim of providing a quality service.


Our management systems define each practice member's responsibilities when looking after you.


The policies, systems and processes in place in our practice reflect our professional and legal responsibilities and follow recognised standards of good practice.


At Mount Wise Dental Practice, we aim to achieve the best results for our patients through clear policies and systems and appropriately trained and competent team members.


We evaluate our practice on a regular basis through audit, peer review and patient feedback, and monitor the effectiveness of our quality assurance procedures.


We work with external agencies, including the British Dental Association, Care Quality Commission and the local Primary Care Trust.



Mount Wise Dental Practice has effective procedures for assuring and enhancing the quality of the services we provide for our patients. The Practice has been part of the BDA's Good Practice Scheme since 2006.


In providing our patients with care of a consistent quality, we will:

  • Provide a safe and welcoming environment

  • Ensure all members of the dental team are appropriately trained

  • Provide patients with information about the practice and the care available and ensure that the patient understands the terms on which care is offered

  • Display indicative treatment charges

  • Explain all treatment options and agree clinical decisions with the patient, explaining the possible risks involved with each option

  • Provide treatment plans based on the agreed treatment with an estimate of the likely costs

  • Obtain valid consent for all treatment. Written consent will be sought for treatments

  • Refer to specialists for investigation or treatment as appropriate and without undue delay

  • Maintain contemporaneous clinical records with an up-to-date medical history for all patients

  • Provide secure storage of patient records to maintain patient confidentiality

  • Explain the procedure to follow for raising a complaint about the service, identifying the practice contact

  • Provide a safe working environment through hazard identification and risk assessment

  • Provide induction training for all new team members

  • Provide job descriptions and contracts of employment to all members of staff.

  • Review and update job descriptions annually to reflect current duties and responsibilities

  • Agree in writing the terms for all self-employed contractors working at the practice

  • Provide ongoing training and identify opportunities for development for all employees

  • Maintain staff records ensuring the following information is up to date:
    - relevant medical history information
    - emergency contact details
    - absence through holiday and sickness
    - performance reviews
    - in-house and external training

  • Ensure that all staff are kept up to date with all practice policies and procedures, including patient charges and the relevant forms


The Team

Team members implement and adhere to the practice policies and procedures which are readily accessible .These are found in the office cupboard in the green file section

All new members of the team receive training in practice-wide procedures, policies and quality assurance activities as part of their induction. Appraisal meetings take place annually and include an assessment of training needs.

We expect everyone working at the practice to:

  • Understand our aims and objectives

  • Have an understanding of the skills and competencies required to deliver the services successfully

  • Understand and participate in our quality assurance activities

  • Dealing with emergencies, including a collapsed patient

Dentists and, Foundation Dentists also understand the policies and procedures for:

  • Referring patients

  • Requesting work from laboratories

  • Ordering materials and equipment

  • Clinical governance requirements and CQC standards of quality and safety

  • Professional and legal requirements affecting dentistry.

All GDC registrants meet their continuing professional development requirements and, as required by the GDC, maintain records of their individual CPD activity. In addition, the practice maintains records of all practice-wide training it provides and training provided for individual members.


The following policies and procedures are in place in the practice and reviewed at least annually to ensure their relevance and currency:

  • Child protection

  • Commitment to staff

  • Complaints handling

  • Confidentiality

  • Consent

  • Data protection and data security

  • Email and internet usage


Employment policies and procedures

  • Adoption, maternity, paternity and parental leave

  • Annual leave

  • Bullying and harassment

  • Disciplinary matters

  • Grievance

  • Redundancy

  • Retirement

  • Sickness/injury absence and pay

  • Stress

  • Staff appraisals

  • Training

  • Underperformance (whistleblowing)

  • Equal opportunities

  • Health and safety policies and protocols

  • Electrical appliance test records

  • Fire precautions and risk assessment

  • Health and safety

  • Infection control

  • Radiation safety

  • Risk assessment, including COSHH

  • Healthcare waste disposal

  • Patient feedback questionnaire

  • Patient fees – collecting money and refunds

  • Patient referral

  • Staff satisfaction survey.

  • Violence and aggression policy

Environmental policy statement

Mount Wise Dental Practice is committed to providing a quality service in a manner that ensures a safe and healthy workplace for our employees and minimises our potential impact on the environment. We operate in compliance with all relevant environmental legislation and strive to use the most energy-efficient and environmentally-friendly best practices in all we do.

Lisa Mullarkey is responsible for ensuring that the policy is implemented. All members of the team, however, have a responsibility to ensure it is complied with. This environmental sustainability policy applies to all of our work activities.

We will ensure good housekeeping with regard to energy efficiency, water efficiency and to waste reduction by segregating, reusing and recycling wherever possible. We will incorporate this training into the induction programme for new members of the team.

We will review this policy on an annual basis.


Energy efficiency

Heating and cooling

We have reduced the overall temperature in the practice by 1oC to reduce consumption.
Thermostats are positioned throughout the practice and set at between 16 °C and 19 °C and checked regularly when the heating is in use. The heating system is thermostatically controlled areas that are not in use routinely, including stock storage areas, the heating is further reduced.

The timers are set to ensure that heating and cooling systems are not operational for long periods outside working hours when the practice is not in use.

Radiators are covered and are routinely checked to ensure that they are free from obstruction.
We have set thermostats, timers and radiator valves correctly and have ensured that radiators are not obstructed.

When the heating is on, we avoid opening windows where possible. Outside doors are kept closed and self-closing mechanisms are fitted to internal doors where appropriate.

Cooling and heating systems do not run at the same time. If it is too warm, we turn down the heating rather than opening windows.

The central heating boiler is serviced regularly and the system checked for leaks at intervals recommended by the service engineers.

We have draught-proofed windows and doors and have insulated the lofts, boilers and pipes, where appropriate.

Practice equipment

We turn off equipment when it is not in use and avoid leaving it in 'stand-by' mode. Equipment with a 'power-down' function have this aspect activated.

Computers, lights, copiers, printers, vending machines and water coolers are turned off overnight.
We only purchase equipment when necessary and will consider the most energy efficient option that meets our needs. Energy consumption can vary greatly depending on equipment age, maintenance, model and manufacturer.


We switch off lights when they are not needed and clean light coverings regularly to increase brightness.

To maximise natural lighting, we ensuring windows are clean and window ledges are not cluttered. Where possible, the practice layout makes best use of natural and artificial lighting.

Modern slim line fluorescent tubes and energy efficient light bulbs are used routinely; they last longer than ordinary bulbs and use less energy.

Water efficiency

We check the water meter regularly to monitor our water usage and to identify any sudden or unexplained increase, which might indicate a leak.

We repair any dripping taps as soon as possible and fit flow restrictors to taps in washrooms.

When purchasing new equipment, we consider the most water-efficient option that meets our needs.

We reduce the quantity of water in our older toilet cisterns by fitted a water-saving device where possible


Reducing waste

We segregate the waste from our practice to allow for recycling of paper, magazines, cardboard, cans and glass, for example.

We monitor local recycling schemes to ensure that we recycle as much waste as possible.

When purchasing stock and other sundry items for the practice, we opt for refills rather than a new product wherever possible.

Purchasing products

We aim to purchase and use environmentally friendly products that are:

  • Non-toxic or have low toxicity and do not pose an environmental hazard

  • Durable

  • Made of recycled materials

  • Able to be recycled, refilled or refurbished

  • Low or reduced energy and/or water consumption

Packaged responsibly (using a reduced amount of packaging that can be recycled).


We undertake regular audits of our procedures and protocols to monitor our service to our patients. On a regular basis, we consider:

  • Inputs

  • Recalls , Patient satisfaction, Radiography

  • Decontamination , Clinical Governance

  • Outcomes

  • Many aspects of the standard of care are considered and improved through varied audits

  • Effectiveness

  • Patient views of effectiveness in improving the standard of service offered here

  • Patient satisfaction levels are monitored and the practice actively seek to improve


Quantitative data

On a monthly basis, we record the following:

  • Total number of patients seen

  • New patients seen

  • Failed appointments (and unused time)

  • Patient safety incidents and the outcome of investigations

  • Positive feedback and compliments

  • Complaints and negative comments

We record the following qualitative data:

  • Results of patient and service audits and improvements

  • Complaint trends and actions taken to improve the service

  • Waiting times and evidence of demand management

  • Staffing and staff turnover

  • CPD activity on individual and practice-wide basis

  • Case mix of clinical presentation and procedure outcome

  • Results of annual patient satisfaction survey on a sample number of patients.


Mount Wise Dental Practice uses clinical governance to ensure we deliver a consistent standard of care to our patients. Our clinical governance framework incorporates the following 12 themes of the NHS clinical governance framework:

  • Infection control

  • Child protection

  • Dental radiography

  • Staff, patient, public and environmental safety assessment

  • Evidence-based practice and research

  • Prevention and public health

  • Clinical records, patient privacy and confidentiality

  • General Staff involvement

  • Clinical staff requirements

  • Patient information and involvement

  • Fair and accessible care

  • Clinical audit and peer review


In relation to Clinical Governance:

  • Everyone understands what the practice is supposed to do

  • Everyone understands their role in delivering the service

  • We monitor all our policies and procedures and how these are implemented

  • We review our policies and procedures on a regular basis to identify where improvements can be made

  • We conduct internal audits

  • We share information and encourage staff members to raise any issues

  • We allow for CPD, staff training and development

  • We allow for (and encourage) patient suggestions

BDA Good Practice Scheme

In our commitment to assuring the quality of the service the Practice is a member of the BDA's Good Practice Scheme. Membership of the Scheme demonstrates our commitment to working to recognised standards of good practice:

  • We aim to provide dental care of a consistently good quality for all patients

  • We only provide care that meets our patients' needs and wishes

  • We aim to make our patients' treatment as comfortable and convenient as possible

  • We will look after our patients' general health and safety while they receive dental care

  • We follow national guidelines on infection control

  • We check for mouth cancer and tell patients what we find

  • We take part in continuing professional development to keep our skills and knowledge up to date

  • We train all staff in practice-wide work systems and review training plans once a year

  • We welcome feedback and deal promptly with any complaints

  • Every member of the practice is aware of the need to work safely under GDC guidelines.



This policy will be subject to regular review and will be updated annually. It was most recently updated in January 2016.



In this practice we take complaints very seriously, and try to ensure that all patients are pleased with their experience of our service. If patients do complain, they will be dealt with courteously and promptly, so that the matter is resolved as quickly as possible. This procedure is based on the following objectives.

Our aim is to react to complaints in the way in which we would wish our own complaint about a service to be handled. We learn from every mistake that we make, and we respond to patients' concerns in a caring and sensitive way.

The person responsible for dealing with any complaint about the service which we provide is Dr Lisa Mullarkey (Principal Dentist).

If a patient complains by telephone, or at the reception desk, we will listen to their complaint, and pass this information to Dr Lisa Mullarkey.

If Dr Lisa Mullarkey is not available at that time, the patient will be told when they will be able to talk to her, and arrangements will be made for this to happen. The member of staff will take brief details of the complaint, and pass them on to Dr Mullarkey. If we cannot arrange this within 48 hours, or if the patient does not wish to wait to discuss the matter, arrangements will be made for someone else to deal with it.

If the patient complains in writing the letter will be passed on to Dr Mullarkey.

If a complaint is about any aspect of clinical care or associated charges it will normally be referred to the dentist, unless the patient does not want this to happen. Dr Mullarkey will acknowledge the patient's complaint in writing and enclose a copy of this code of practice as soon as possible, and in any event within five working days.


We will aim to resolve the matter within fourteen working days of the complaint being received.

Proper and comprehensive records are kept of any complaint received.

If patients are not satisfied with the result of our procedure then the issue may be raised with the local PALS (Patient Association Liaison Service) who will listen and give appropriate advice.

This Code of Practice is reviewed annually.

Patient Privacy Policy

This policy outlines how we keep your personal information safe as per GDPR compliance rules.

The Team
Patiet Privacy Policy
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