Updated 24 August 2018
We undertook a focused inspection of Mr Gavin Maw – Houghton-le-Spring dental practice on 7 August 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 with remote access to a specialist dental adviser.
We undertook a comprehensive inspection of Mr Gavin Maw – Houghton-le-Spring on 8 May 2018 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 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 Mr Gavin Maw – Houghton-le-Spring dental practice 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:
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 8 May 2018.
Background
Gavin Maw’s dental practice is in Houghton-le-Spring and provides NHS and private treatment to adults and children.
The practice is situated on the ground floor of a building. The entrance to the practice has a small step. A portable ramp was available for people who use wheelchairs and those with pushchairs.
Limited car parking spaces are available outside the practice.
The dental team includes the principal dentist, two associate dentists, the practice manager and five dental nurses who also perform reception duties. The practice has two treatment rooms.
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, one dental nurse 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 and Wednesday 8.30am to 6pm
Tuesday 8.30am to 7pm
Thursday 8.30am to 5pm
Friday 8.30am to 4pm.
Our key findings were:
- The provider had systems to help them manage risk. A fire risk assessment of the premises had been carried out since our comprehensive inspection. Appropriate fire detection and fire-fighting equipment were in place with regular checks for these. All hazardous materials were risk assessed in line with the Control of Substances Hazardous to Health Regulations 2002.
- Infection prevention and control systems were reviewed and amended to comply with national guidance. This included systems to segregate and correctly dispose of waste, maintain and service sterilisation equipment and environmental cleaning processes.
- Infection prevention and control audit processes were effective.
- Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
- The principal dentist had assessed the needs of all population groups in line with the Equality Act 2010.
- Policies were dated, reviewed and signed by all members of staff to indicate they had been read and understood.
- The inspection frequency of the practice’s pressure vessels was reviewed and an inspection of the compressor had been completed since our comprehensive inspection.
- The practice's protocols for medicines management were amended to ensure all medicines were stored safely and securely.