Updated 9 January 2020
We undertook a focused inspection of Ashby Fields Dental Centre on 3 December 2019. This inspection was carried out to review in detail the actions taken by the registered provider to improve the quality of care and to confirm that the practice was now meeting legal requirements.
The inspection was led by a CQC inspector.
We undertook a comprehensive inspection of Ashby Fields Dental Centre on 1 April 2019 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We found the registered provider was not providing well led care and was in breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can read our report of that inspection by selecting the 'all reports' link for Ashby Fields Dental Centre on our website www.cqc.org.uk.
As part of this inspection we asked:
• Is it well-led?
When one or more of the five questions are not met we require the service to make improvements and send us an action plan (requirement notice only). We then inspect again after a reasonable interval, focusing on the area(s) where improvement was required.
Our findings were:
Are services well-led?
We found this practice was providing well-led care in accordance with the relevant regulations.
The provider had made improvements in relation to the regulatory breach we found at our inspection on 1 April 2019.
Background
Ashby Fields Dental Practice is in Daventry, a town in western Northamptonshire. It provides NHS treatment to patients exempt from payment and private treatment to adults and children.
Services provided include general dental services, implants, orthodontics and cosmetic procedures.
There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces, including those for blue badge holders, are available in a free public car park in front of the premises.
The dental team includes five dentists, three dental nurses, two trainee dental nurses, one dental hygiene therapist and four receptionists, (one of the receptionists also works as a dental nurse). Two practice managers share administrative duties.
The practice has five treatment rooms; all of which are on ground floor level.
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.
During the inspection we spoke with the principal dentist and one of the practice managers. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open: Monday from 9am to 6pm, Tuesday, Wednesday and Thursday from 9am to 5.30pm, Friday from 9am to 5pm.
Our key findings were:
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The provider demonstrated their commitment to improvement and had made significant efforts to strengthen their governance arrangements.
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Systems and processes were in place to enable the registered person to assess, monitor and improve the quality and safety of the services being provided. Systems to identify risks relating to the health, safety and welfare of service users and others were in place and working effectively.
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Incident reporting procedures were in place and working effectively. As a result, staff shared learning when things went wrong.
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A system had been implemented to enable management to monitor staff training requirements.
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Staff appraisals had been completed.
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Management ensured staff completed learning in relation to the Mental Capacity Act 2005 and that they understood how this related to their role.
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Safeguarding procedures had been reviewed by management and all staff had completed training to the expected level.
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Risks presented by legionella, fire and sharps use had been suitably mitigated.
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Staff had been re-trained in infection control processes regarding laboratory work.
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There were suitable risk assessments in place to minimise the risk that can be caused from substances that are hazardous to health.
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Systems had been strengthened in relation to legislative checks required for agency staff.
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Management had monitoring systems which included checks to ensure that clinical staff had valid indemnity.
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We saw that rectangular collimators were fitted to X-ray machines to reduce radiation dose to patients.
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Guidance regarding basic periodontal examination (BPE) from the British Society of Periodontology had been reviewed.