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Inspection Summary


Overall summary & rating

Updated 2 May 2017

During our announced comprehensive inspection of this practice on 11 October 2016 we found breaches of legal requirements of to the Health and Social Care Act 2008 in relation to regulation 17- Good Governance.

We undertook this focused inspection to check that the provider now met legal requirements. This report only covers our findings in relation to these requirements. You can read the report from our previous comprehensive inspection by selecting the 'all reports' link for Kenneth Ng Surgery Limited at www.cqc.org.uk

Are services Well-led?

We found that this practice was providing well-led care in accordance with the relevant regulations.

Key findings

  • The provider had failed to address many of the shortfalls we had identified at our previous inspection. However, immediately following this second inspection the provider sent us sufficient evidence to demonstrate that the practice was now adequately well-led.

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

  • Embed newly implemented improvements into the practice and ensure they are sustained in the long- term
Inspection areas

Safe

No action required

Updated 29 November 2016

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

Most risks to staff and patients had been identified and control measures put in place to reduce them and the practice’s decontamination procedures met national guidance. Arrangements were in place to safeguard children and vulnerable adults from abuse, and to respond appropriately to a range of medical emergencies. Equipment was well maintained. However, learning from significant events was not shared across the staff team to prevent their reoccurrence; emergency equipment and medicines did not meet national recommended guidelines, and there was no system in place to ensure that national safety alerts were disseminated and actioned appropriately.

Effective

No action required

Updated 29 November 2016

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

There was a small and established staff team at the practice who received regular appraisal of their performance, and who were up to date with their continuing professional development. Staff had a good understanding of the Mental Capacity Act 2005, and its relevance in obtaining valid consent for a patient who lacked the capacity to make decisions for themselves. Patients were referred to other services appropriately. However, it was not possible for us to ascertain from the dental care records if patients’ needs were fully assessed, and if care and treatment was delivered in line with current standards and evidence based guidance, as a lot of essential information about patients was not recorded.

Caring

No action required

Updated 29 November 2016

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

Patients spoke highly of the dental treatment they received, and of the caring and empathetic nature of the practice’s staff. Patients told us they were involved in decisions about their treatment, and did not feel rushed in their appointments.

Responsive

No action required

Updated 29 November 2016

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

The practice had good facilities and was well equipped to treat patients and meet their needs. Routine dental appointments were readily available, as were urgent on the day appointment slots and patients told us it was easy to get an appointment with the practice. Good information was available for patients both in the practice’s leaflet and on the web site. The practice had made adjustments to accommodate patients with a disability and the premises were fully wheelchair accessible.

Information about how to complain was not easily available to patients, although the practice responded in an empathetic and appropriate way to issues raised by them.

Well-led

No action required

Updated 2 May 2017

Are services well-led

We noted some improvements had been implemented since our previous inspection. Untoward incidents were better managed, missing medical equipment had been purchased, staff rehearsed fire evacuation drills and patients’ dental care records were of a better standard overall. However, the provider had failed to address many other shortfalls we had identified in our previous report. For example, there was no system to ensure MHRA alerts were managed effectively; staff did not undertake emergency medical simulations; COSHH sheets were not available for some hazardous substances within the practice and stock control was poor. Patients’ referrals were not monitored, recording of patients’ consent to treatment was limited and audits were not undertaken to assess the quality of patient X-rays. However, immediately following this second inspection the provider sent us adequate information to demonstrate that he now complied with the breach in regulation.