Archived: Lakeside Orthodontics

Updated 30 December 2016

At this review we asked the questions - Is it well led? - to follow up the concerns identified at the last inspection. We undertook a desk based follow up review of Lakeside Orthodontics on the 20 December 2016. This inspection was carried out to check that improvements to meet legal requirements planned by the practice after our inspection in March 2016 had been made. We inspected the practice against one of the five questions we ask about services. This is because the service was not meeting some legal requirements.

This review was undertaken by a CQC Lead Inspector on 20 December 2016.

The inspection was carried out as a focused desk based review. The practice submitted an action plan following the comprehensive inspection and further evidence to demonstrate that they had made the necessary improvements and were now meeting the regulation identified as being breached at the last inspection. This information was reviewed by the inspector.

Updated 30 December 2016

We carried out an announced comprehensive inspection at Lakeside Orthodontics on 22 March 2016 and at this time breaches of legal requirements were found. After the comprehensive inspection the practice wrote to us and told us that they would take action to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

Regulation 17 HSCA (RA) Regulations 2014 Good governance

Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed

On 20 December 2016 we carried out a follow up review of this service under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was carried out to check whether the provider had completed the improvements needed and identified during the comprehensive inspection in March 2016.

We reviewed the practice against one of the five questions we ask about services: is the service well-led? This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Lakeside Orthodontics on our website at www.cqc.org.uk

We reviewed information Lakeside Orthodontics had sent us as part of this review, checked whether they had followed their action plan and to confirm that they now met the legal requirements.

Our findings were:

Are services well-led?

We found that this practice was now providing well-led care in accordance with the relevant regulations.

Background

The practice is situated in West Kirby, Wirral. It has a waiting/reception area, three treatment areas, a decontamination room, staff facilities and administrative offices. The practice has one principal specialist orthodontist, three orthodontic therapists, five qualified dental nurses and a practice manager. The practice is a specialist dental surgery providing orthodontic treatment to both adults and children. Orthodontics is specialist dental treatment that corrects irregularities of alignment of the teeth in order to improve position, appearance and function of crooked or abnormally arranged teeth. They provide these services predominantly to NHS patients and also to some private patients. The practice receives dental referrals from dental practices all over the North West of England and North Wales.

The practice is open:

Monday to Thursday 9am - 5.30pm and Friday 9am – 4pm

The principal orthodontist is registered with the Care Quality Commission (CQC) as an individual and is legally responsible for making sure that the practice meets the requirements relating to safety and quality of care, as specified in the regulations associated with the Health and Social Care Act 2008.

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Our key findings were:

We found that this practice was now providing well led care in accordance with the relevant regulations.

• A recruitment policy had been implemented that included obtaining the required information for people working at the practice such as photographic identification, references, qualifications and Disclosure and Barring Service (DBS) checks.
• Staff now have signed contracts and job descriptions reflective of their role.

Governance arrangements included:

• An audit programme was planned and included audits such as infection prevention and control, radiographs and clinical waste.

• Risks such as infection prevention and control, radiation, fire and Legionella had been assessed and action taken to mitigate the risks.
• A patient satisfaction survey had been undertaken.
• Paper patient records were stored securely.

We found that the practice had acted upon other recommendations made at the previous inspection to improve the service and care. For example:

• Staff had undertaken safeguarding training at a level relevant to their role and a revised safeguarding policy was in place that included vulnerable adults.
• Staff had been appraised and a mandatory training schedule had been implemented which would be monitored.
• The cleaning policy reflected national guidance on the cleaning of dental premises.
• The business plan has been reissued and staff had signed to say they read and understood it.