Updated 20 March 2020
We undertook a focused inspection of Passage House Dental Practice on 11 February 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 was supported by a specialist dental adviser.
We undertook a comprehensive inspection of Passage House Dental Practice on 19 June 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 19 fit and proper persons employed 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 Passage House Dental Care 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. We then inspect again after a reasonable interval, focusing on the area where improvement was required.
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 19 June 2019.
Background
Passage House Dental Care is in Henbury, Bristol and provides NHS and private treatment for adults and children.
There is level access for people who use wheelchairs and those with pushchairs. There are two patient car parking spaces, which are available, at the front of the practice. There is also one hour’s parking available near the practice.
The dental team includes seven dentists, eight dental nurses, one dental hygienist and four receptionists and a practice manager. The practice has five treatment rooms.
The practice is owned by a partnership and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run. The registered manager at Passage House Dental Care is the senior partner.
During the inspection we spoke with the registered manager and the practice manager. We looked at practice policies and procedures and other records about how the service is managed in relation to the breach of regulation and areas where we told the provider they should improve upon the last inspection.
The practice is open:
- Monday 8:30am – 5:30pm
- Tuesday 8:30am – 6:30pm
- Wednesday 8:30am – 5pm
- Thursday 8am – 5:30pm
- Friday 8am – 4pm
Our key findings were:
- Effective systems were in place to ensure all information specified within schedule 3 of the Health and Social Care Act 2008 (regulated activities) was in place for recruited staff.
- The provider had addressed the outstanding action for the use of X-ray equipment.
- The outstanding risks had been mitigated in regards to fire safety.
- NHS prescriptions were held securely and monitored for their use.
- An audit had been completed for prescribing antibiotic medicines, which took into account the guidance provided by the Faculty of General Dental Practice.
- Patient referrals to other dental or health care professionals were centrally monitored to ensure they were received within a timely manner and not lost.