Updated 13 February 2019
We undertook a focused follow up inspection of Sefton Dental Centre on 24 January 2019. 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 carried out by a CQC inspector.
We undertook a comprehensive inspection of Sefton Dental Centre on 26 September 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 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 Sefton Dental Centre on our website www.cqc.org.uk.
As part of this inspection we asked if care and treatment was:
• 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 breaches we found at our inspection on 26 September 2018.
Background
Sefton Dental Centre is in Bootle, Merseyside and provides NHS treatment for adults and children. Some private treatment is also available.
There is level access for people who use wheelchairs and those with pushchairs. There is no dedicated car parking for the practice. There is access to a space for disabled drivers which can sometimes be arranged for patients that require this.
The dental team includes three dentists, five dental nurses, one of whom is a trainee, two dental hygiene therapists and two receptionists. A practice manager and a human resources (HR) manager work between this practice and a sister site. The practice has four treatment rooms.
The practice is owned by an organisation 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 Sefton Dental Centre is the principal dentist and owner of the organisation.
During the inspection we spoke with the practice manager and HR manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open Monday to Thursday, from 7.45am to 8pm, and on Friday from 7.45am to 5.30pm.
Our key findings were:
The provider had made improvements to governance systems across the practice, in accordance with the fundamental standards of care. This included:
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Records held in respect of recruitment were now more complete, including information on staff immunity to Hepatitis B. Where evidence of immunity was not available, for example, in cases of trainees who had not completed the Hepatitis B vaccination course, risk assessments were in place to minimise the likelihood of injury from sharps.
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Disclosure and Barring Service (DBS) checks were in place for all staff working at the practice. We saw that recruitment files also held all documents as required by Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) 2008, including proof of address and career history.
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All staff were now receiving performance reviews. Newer staff at the practice were receiving regular one-to-one meetings to review their induction training and on-going learning needs.
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Systems for reporting, analysing and sharing any lessons learned from significant events were in place.
Further improvements had been made by the provider in relation to:
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Management of radiation and radiation equipment.
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Staff training related to safety at work.
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Infection control
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Audit and continuous improvement
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Prescription pad security
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Engagement of staff through feedback surveys.