Updated 27 January 2020
We carried out this unannounced inspection on 21 November 2019 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 second inspector.
To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:
• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• 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 well-led?
We found this practice was not providing well-led care in accordance with the relevant regulations.
Background
Limes Dental Centre is in Worsley, Manchester and provides NHS and private treatment for adults and children.
Portable ramps are available for people who use wheelchairs and those with pushchairs. On street parking is available near the practice.
The team is comprised of the practice owner and a part time dental therapist. There is a practice manager who provides oversight of the service and a receptionist. The practice currently employs the services of locum dentists and agency dental nurses to provide the service. There are 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 practice owner, one locum dentist, one agency dental nurse and an agency receptionist. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday 9am to 1pm and 2pm to 5.30pm
Tuesday 9am to 12.30pm
Wednesday and Thursday 9am to 1pm and 2pm to 6pm
Friday 9am to 1pm.
Our key findings were:
- The practice appeared to be visibly clean and tidy. Some maintenance of the building and fixtures was required.
- Infection control procedures require improvement.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available. The pads for the automated external defibrillator had expired.
- The provider had some systems to help them manage risk to patients and staff.
- The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The staff recruitment procedures did not reflect current legislation.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
- The provider had information governance arrangements.
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.
- Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
Full details of the regulations the provider is not meeting are at the end of this report.