Updated 29 August 2018
We undertook a focused inspection of St Helen’s Dental Surgery on 09 July 2018. 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 who was supported by a specialist dental adviser.
Previously, we undertook a comprehensive inspection of St Helen’s Dental Surgery on 09 January 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. During that inspection we found the registered provider was providing a safe, effective, caring and responsive service but was not providing well led care in accordance with the relevant regulations 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 St Helen’s Dental Surgery on our website www.cqc.org.uk.
When one or more of the five questions are not met we require the service to make improvements and send us an action plan. We then inspect again after a reasonable interval, focusing on the area where improvement was required.
As part of this inspection we asked:
Is it well-led?
Our findings were:
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 09 January 2018.
Background
The practice is located in Ashby De La Zouch, a market town in North West Leicestershire. It provides NHS treatment to patients of all ages. At the time of our inspection, the practice was accepting new NHS patients for registration.
There is level access for people who use wheelchairs and pushchairs. Car parking spaces are available in the practice’s own car park.
The dental team includes the practice manager, one dentist, four dental nurses, (including the practice manager) and one receptionist. The practice has two treatment rooms, both located on the ground floor.
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.
The practice is open: Monday to Thursday from 8:45am to 12pm and from 1:45pm to 5:45pm and on Friday from 8:45am to 1:45pm.
Our key findings were:
The practice had implemented a policy and process for reporting and investigating significant events.
The practice had implemented systems for monitoring and improving quality, for example audit activity.
Risk assessments had been conducted in areas such as legionella and fire safety.
The practice showed they were receiving and reviewing patient safety and medicines alerts from the Medicines and Healthcare Products Regulatory Authority.
Policies had been reviewed or were newly implemented; they were specific to the practice.
Recruitment processes had been strengthened to reflect legislative requirements.
Processes for ensuring all emergency medicines and equipment were available had been improved.
The practice had implemented a safer sharps system.
Rubber dam was available and was in use by the dentist.
Staff awareness of the requirements of the Mental Capacity Act 2005 and Gillick competence had increased.
The practice had obtained a hearing loop to help any patients with hearing problems.
Systems for ensuring security of prescription pads had improved; we noted this could be further strengthened.
The provider had implemented a system for monitoring and improving quality of the service.
We found that the provider had taken steps to mitigate the risks relating to the health, safety and welfare of patients and others who might be at risk.