You are here

Archived: Kensington Dental Spa Limited

The provider of this service changed - see new profile

Inspection Summary


Overall summary & rating

Updated 10 December 2015

We carried out an announced comprehensive inspection on 16 September 2015 to ask the practice the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

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

Are services effective?

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

Are services caring?

We found that this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

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

Are services well-led?

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

Background

Kensington Dental Spa provides both private and NHS treatment to patients. The practice treats adult patients from a range of cultures and backgrounds.

The practice staffing consisted of 10 part-time dentists, four part-time dental nurses, a practice manager who was also the owner and two receptionists.

The practice opening hours were: Monday to Friday – 9.00am to 5:00pm.

The practice manager is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is run.

We viewed 13 CQC comment cards that had been completed by patients, about the services provided. All had positive comments about the staff and the services provided. In addition, we spoke with three patients who all provided positive feedback about the practice and the dental treatment they had received. Comments particularly focussed on the caring nature of the staff and the quality of the service provided.

Our key findings were:

  • Patients’ needs were assessed and treatment was planned and delivered in line with current guidance such as from the National Institute for Health and Care Excellence (NICE) and Faculty of General Dental Practitioners (FGDP).

  • The practice had oxygen and appropriate medicines to respond to a medical emergency in line with British National Formulary and Resuscitation Council (UK) guidance. However, staff did not have access to an automated external defibrillator (AED).

  • Clinical staff were up to date with their continuing professional development (CPD).

  • There was lack of effective processes in place to ensure patients were safeguarded from the risks of abuse.

  • Governance arrangements were not clear and the practice did not have processes in place such as undertaking regular audits and obtaining staff feedback to assess and monitor the quality of the service.

  • The practice was not carrying out risk assessments to ensure the health and safety of staff and patients.

  • There was lack of an appropriate complaints handing process in place.

  • The practice did not hold regular staff meetings and formal staff appraisals had not been undertaken.

We identified regulations that were not being met and the provider must:

  • Ensure that systems and processes are established to investigate, respond to and learn from significant events.

  • Ensure that systems and processes are established and operated effectively to safeguard service users from abuse.

  • Ensure that appropriate governance arrangements are in place for the safe running of the service by establishing systems to monitor and assess the quality of the service.

  • Ensure that the practice is in compliance with its legal obligations under Ionising Radiation Regulations (IRR) 1999 and Ionising Radiation (Medical Exposure) Regulation (IRMER) 2000.

  • Ensure procedures are in place to assess the risks in relation to the Control of Substances Hazardous to Health (COSHH) 2002 Regulations.

  • Ensure audits of various aspects of the service, such as radiography and dental care records are undertaken at regular intervals to help improve the quality of service. Practice should also ensure all audits have documented learning points and the resulting improvements can be demonstrated.

  • Ensure that the registered person establishes and operates effectively an accessible system for identifying, receiving, recording, handling and responding to complaints by service users.

You can see full details of the regulations not being met at the end of this report.

There were areas where the provider could make improvements and should:

  • Review availability of equipment to manage medical emergencies giving due regard to guidelines issued by the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.

  • Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.

  • Review the practice’s sharps procedures giving due regard to the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

  • Review the practices’ current risk assessments and ensure a Legionella risk assessment is undertaken giving due regard to guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’.
Inspection areas

Safe

Improvements required

Updated 10 December 2015

We found this practice was not providing safe care in accordance with the relevant regulations. We have told the provider to take action (see full details of this action in the Requirement Notices at the end of this report).

Recommended medicines and equipment such as medical oxygen were available to manage a medical emergency. However, the practice did not have an automated external defibrillator (AED) in line with Resuscitation Council (UK) guidance.

Staff at the practice including the practice manager, who was the safeguarding lead, had not completed safeguarding training and the provider did not have a clear safeguarding policy or procedure in place for staff to refer to.

The practice did not have procedures in place to investigate, respond to and learn from significant events and complaints The practice had not carried out any risk assessments although there were processes to ensure equipment and materials were well maintained and safe to use, for example portable appliance testing occurred annually. A radiation protection file to confirm the maintenance of the X-ray machine had not been set up, there was no record of Health and Safety Executive notification and no maintenance logs were in place.

The provider assured us on the day of the inspection and following our visit that they would address these issues by notifying staff of the correct procedures to follow, provide staff training, and put immediate procedures in place to manage risks.

Effective

No action required

Updated 10 December 2015

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

The practice provided evidence-based care in accordance with relevant, published guidance, for example, from Faculty of General Practitioners (FGDP). The practice monitored patients’ oral health and gave appropriate health promotion advice. Staff explained treatment options to ensure that patients could make informed decisions about any treatment. The practice worked well with other providers and followed up on the outcomes of referrals made to other providers. Staff engaged in continuous professional development (CPD) and were meeting the training requirements of the GDC.

Caring

No action required

Updated 10 December 2015

We found that this practice was providing caring services in accordance with the relevant regulations.

We received 13 completed CQC comment cards and spoke with 3 patients. The feedback was very positive. Patients were happy with the service the received. They described staff as helpful and felt that a caring service was being provided.

The provider had taken reasonable steps to ensure patient confidentiality was protected. Patients’ information was held securely, both electronically and in paper records. Computers were password protected so that they could not be accessed by unauthorised persons.

Responsive

No action required

Updated 10 December 2015

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

Patients had appropriate access to the service. Information was made available to patients through leaflets and posters in the patient waiting area. Urgent on the day appointment slots were available during opening hours and appropriate arrangements were in place for out of hours emergencies.

However, there was lack of suitable systems in place for patients to make a complaint about the service if required.

Well-led

Improvements required

Updated 10 December 2015

We found that this practice was not providing well-led care in accordance with the relevant regulations. We have told the provider to take action (see full details of this action in the Requirement Notices section at the end of this report).

Policies and procedures were not effective to ensure the smooth running of the service. Most policies were generic templates and they had not been adapted to the practice. There were no clear governance arrangement in place. Practice meetings were not being held and there were no mechanisms in place to update staff. There were no processes in place to oversee staff development. Staff appraisals did not take place and there was no evidence of how staff were supported. Audits were not being completed and there were limited mechanisms in place for obtaining and monitoring feedback for continuous improvements.