28 October 2020
During an inspection looking at part of the service
We undertook a follow up desk-based review of Armitage dental practice on 28 October 2020. 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 who had access to remote advice from a specialist dental adviser.
We undertook a comprehensive inspection of Armitage dental practice on 1 October 2019 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 and was in breach of Regulation 17 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 Armitage dental practice on our website www.cqc.org.uk.
As part of this inspection we asked:
- Is it well-led?
When one or more of the five questions are not met, we require the service to make improvements and send us an action plan (requirement notice only). We then inspect again after a reasonable interval, focusing on the area where improvement was required.
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 1 October 2019.
Background
Armitage Dental Practice is in Armitage, Staffordshire, and provides NHS and private dental treatment to adults and children.
There is level access for people who use wheelchairs and those with pushchairs. The practice has a small car park at the rear and car parking spaces are also available at the front of the practice and on local side roads.
The dental team includes two dentists and two dental nurses, one of whom is also the receptionist/practice manager. The practice has one treatment room and a separate decontamination room.
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 checked that the registered provider’s action plan had been implemented. We reviewed a range of documents provided by the registered provider.
The practice is open: Monday 9.30am to 6.30pm, Tuesday 8.30am to 4.45pm, Wednesday 8.30am to 1pm, Thursday 8.30am to 5.15pm, Friday 9.30am to 4.45pm. The practice is closed for lunch for one hour each day, apart from Wednesday.
- Our key findings were:
- Infection prevention and control audits had an action plan and evidence of learning and action taken.
- Risk assessments were available for each hazardous substance in use at the practice, we were told that material safety data sheets were available on-line for review.
- Staff had completed training regarding data security awareness and the associate dentist had completed continuing professional development in respect of dental radiography.
- The practice had implemented a system for recording, investigating and reviewing incidents or significant events with a view to preventing further occurrences and ensuring that improvements are made as a result.
- Records relating to people employed at the practice were stored in compliance with legislation, taking into account current guidance.
- The dentist had completed a “simple audit for prescribing activity” using a toolkit provided by the British Dental Association, taking into account the guidance provided by the Faculty of General Dental Practice.
- We were not provided with evidence to demonstrate improvements to the practice protocols regarding auditing patient dental care records to check that necessary information is recorded.
- Improvements had been made to the practice's complaint handling procedures, an accessible system for identifying, receiving, recording, handling and responding to complaints by service users had been established, although the ‘Dental Practice Complaints Procedure – Information for Patients’ had not been fully completed.
- Further work should be completed to ensure that all policies and procedures in the practice quality manual have been adapted to meet the needs of the practice.
- Further work is required to fully complete the practice fire risk assessment, although the fire risk assessment states that staff have completed fire safety training, we were not provided with evidence to demonstrate this.
There were areas where the provider could make improvements. They should:
- Improve the practice protocols regarding auditing patient dental care records to check that necessary information is recorded.
- Take action to ensure the service takes into account the needs of patients with disabilities and to comply with the requirements of the Equality Act 2010.