Clough Dental Surgery

We undertook a follow up focused inspection of Clough Dental Surgery on 23 September 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 led by a CQC inspector who was supported by a specialist dental adviser.

We undertook a comprehensive inspection of Clough Dental Surgery on 15 July 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 X 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 Clough Dental Surgery 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 areas 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 15 July 2019.

Background

Clough Dental Surgery is in Sowerby Bridge and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice.

The dental team includes three dentists, six dental nurses (two of who are trainees), two dental hygienists and a practice manager. The practice has three 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 Clough Dental Surgery is the principal dentist.

During the inspection we spoke with one dental nurse and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday, Wednesday, Thursday and Friday from 9:00am to 5:30pm

Tuesday from 8:30am to 6:30pm

Our key findings were:

• Improvements had been made to the systems and processes for managing the risks associated with the carrying out of the regulated activities. These included the risks associated with fire and Legionella.
• The medical emergency equipment and medicines reflected nationally recognised guidance.
• Improvements had been made to the overall governance arrangements to ensure ongoing compliance with the regulations.

There were areas where the provider could make improvements. They should:

• Improve the practice's processes for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health (COSHH) Regulations 2002, to ensure risk assessments are undertaken.

We carried out this announced inspection on 15 July 2019 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a CQC inspector who was supported by a specialist dental adviser.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

These questions form the framework for the areas we look at during the inspection.

Our findings were:

Are services safe?

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

Are services effective?

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

Are services caring?

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

Are services responsive?

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

Are services well-led?

We found that this practice was not providing well-led care in accordance with the relevant regulations.

Background

Clough Dental Surgery is in Sowerby Bridge and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice.

The dental team includes three dentists, six dental nurses (two of who are trainees), two dental hygienists and a practice manager. The practice has three 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 Clough Dental Surgery is the principal dentist. The other partner has now retired and has no responsibility for the running of the service. We advised the registered manager of the need to review their registration.

On the day of inspection, we collected 49 CQC comment cards filled in by patients.

During the inspection we spoke with one dentist, two dental nurses and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Our key findings were:

• The practice appeared clean and well maintained.
• The provider had infection control procedures in place. Improvements could be made to some of these procedures.
• Staff knew how to deal with emergencies. On the day of inspection not all medical emergency equipment was available as described in nationally recognised guidance. The pads for the automated external defibrillator (AED) had passed their use by date.
• Improvements could be made to the process for managing the risks associated with the carrying on of the regulated activities. These include the risks associated with Legionella, fire and the control of substances hazardous to health.
• The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The provider had staff recruitment procedures in place. Improvements could be made to the process for checking medical indemnity for the clinicians.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• Staff provided preventive care and supporting patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• Staff felt involved and supported and worked well as a team.
• The provider asked staff and patients for feedback about the services they provided.
• The provider dealt with complaints positively and efficiently.
• The provider had suitable information governance arrangements.

We identified regulations the provider was not complying with. They must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

Full details of the regulation the provider was not meeting are at the end of this report.

There were areas where the provider could make improvements. They should:

• Review the practice’s protocols for the use of rubber dam for root canal treatment taking into account guidelines issued by the British Endodontic Society.