Background to this inspection
Updated
9 November 2016
We carried out a desk based review of this service under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider had completed the requirements identified during the comprehensive inspection carried out in March 2016. The checks made were to ensure the provider was now meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.
This review was undertaken by a CQC Lead Inspector on 18 October 2016.
The inspection was carried out as a focused desk based review. The practice submitted an action plan following the comprehensive inspection and further evidence to demonstrate that they had made the necessary improvements and were now meeting the regulation identified as being breached at the last inspection. This information was reviewed by the inspector.
To get to the heart of patients’ experiences of care and treatment, we ask the following five questions:
At this review we asked the question - Is it safe? And is it well led? - to follow up the concerns identified at the last inspection.
Updated
9 November 2016
We carried out an announced comprehensive inspection at Banks House Dental on 30 March 2016 and at this time breaches of legal requirements were found. After the comprehensive inspection the practice wrote to us and told us that they would take action to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:
Regulation 13 HSCA (RA) Regulations 2014 Safeguarding service users from abuse and improper treatment
Regulation 17 HSCA (RA) Regulations 2014 Good Governance
On 18 October 2016 we carried out a focused review of this service under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The review was carried out to check whether the provider had completed the improvements needed and identified during the comprehensive inspection in March 2016. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Banks House Dental Practice on our website at cqc.org.uk
Background
The practice is situated in West Kirby, Wirral and has waiting areas, a reception area, three treatment rooms, a decontamination room, a staff room/storage area and an administrative office. The practice has three dentists, two hygienists, six qualified dental nurses, a receptionist and a practice manager. The practice provides primary dental services to predominantly NHS patients and some private patients. The practice is open as follows:
Monday 9am – 7pm
Tuesday and Wednesday 8.30am – 5.30pm
Thursday and Friday 9am - 5.30pm
One of the principal dentists is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is
run.
CQC inspected the practice on 30 March 2016 and asked the provider to make improvements in relation to:
- Ensuring staff recruitment records contained all the required information to be held relating to staff and with relevance to their role.
- Ensuring a system was implemented by which patient views are analysed, acted on and feedback used to help improve services.
- Ensuring an effective system was established to assess, monitor and mitigate the various risks arising from undertaking of the regulated activities.
- Ensuring all staff were trained to an appropriate level for their role in safeguarding of children and protection of vulnerable adults and aware of their responsibilities, including understanding of and responsibilities under the Mental Capacity Act 2005.
We checked these areas as part of this focussed inspection and found these had been resolved.
The findings of this review were as follows:
We found that this practice was now providing safe and well led care in accordance with the relevant regulations.
- All staff working at the practice had a relevant Disclosure and Barring Service (DBS) check undertaken that was appropriate to their role.
- A patient satisfaction survey had been undertaken and findings had been discussed at a practice meeting.
- Identified health and safety risks had now been actioned with controls in place to mitigate the risks.
- Staff had received training in safeguarding at appropriate levels for their role and this included training and awareness of their responsibilities under the Mental Capacity Act 2005
- Staff meetings were organised and documented to include dissemination of governance issues such as dissemination of lessons learnt from significant incidents, events and complaints and sharing improvements from audits and patient feedback.
We found that the practice had acted upon other recommendations made at the previous inspection to improve the service and care. For example:
- The door leading to the local decontamination unit (LDU) was secure and only authorised staff could access it.
- Fire safety training was reviewed and included fire safety/evacuation drills.
- The practice had access to interpreter services for patients who do not speak English as their first language.
- The cleaning schedule has been reviewed and followed National Patient Safety Association (NPSA) guidance on the cleaning of dental premises, including having suitable cleaning equipment in place.
- The training, learning and development needs of staff members had been reviewed and included appraisals at appropriate intervals and ensuring staff were up to date with mandatory training including safeguarding, infection control and fire safety.
- The business continuity plan has been updated, reissued and communicated internally and externally.