Secrets Medical Ltd

We carried out this announced focused inspection on 12 October 2021 under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a Care Quality Commission, (CQC), inspector who was supported by a specialist dental adviser.

To get to the heart of patients’ experiences of care and treatment, we asked the following three questions:

• Is it safe?

• Is it effective?

• Is it well-led?

These questions form the framework for the areas we look at during the inspection.

Our findings were:

Are services safe?

We found this practice was not providing safe care in accordance with the relevant regulations.

Are services effective?

We found this practice was providing effective care in accordance with the relevant regulations.

Are services well-led?

We found this practice was not providing well-led care in accordance with the relevant regulations.

Background

Secrets Spa Limited is in Southport and provides private dental care and treatment for adults and children.

There is a ramp at the front entrance of the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for people with disabilities, are available directly outside the practice with additional street parking nearby.

The dental team includes two dentists, two dental nurses, a practice manager, a physiotherapist and two receptionists. The practice has two dental treatment rooms and a third treatment room for the physiotherapist and aesthetic services. A visiting dentist attends as necessary to place dental implants.

The practice is owned by a company and as a condition of registration must have a person registered with the CQC as the registered manager. Registered managers 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 registered manager at Secrets Spa Limited is the practice manager.

During the inspection we spoke with the director, one dentist, one dental nurse, one receptionist and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Friday 8.30 am to 5pm

Our key findings were:

• The practice appeared to be visibly clean, tidy and well-maintained.
• The provider had implemented standard operating procedures in line with national guidance on COVID-19. There was no evidence that face masks were appropriately fit tested.
• Improvements were needed to ensure the validation and auditing of infection control procedures to meet published guidance.
• The emergency medicines and life-saving equipment were not in line with nationally agreed standards and guidance.
• The provider did not have systems to help them identify and manage risk to patients and staff.
• The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The provider’s staff recruitment procedures did not reflect current legislation.
• The provider did not have a system to ensure staff were up to date with training.
• The clinical staff provided patients’ care and treatment in line with current guidelines. There was no oversight of the dental implant service.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• Staff provided preventive care and supported patients to ensure better oral health.
• The provider did not have effective leadership and a culture of continuous improvement.
• The provider asked patients for feedback about the services they provided.

We identified regulations the provider was not complying with. They must:

• Ensure care and treatment is provided in a safe way to patients
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

Full details of the regulations the provider is not meeting are at the end of this report.

There were areas where the provider could make improvements. They should:

• Take action to register the practice’s use of dental X-ray equipment with the Health and Safety Executive in line with the Ionising Radiation Regulations 2017 (IRR17).