Updated 28 October 2019
We undertook a focused inspection of C M Desai Limited - Thurncourt on 29 August 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 C M Desai Limited - Thurncourt on 20 November 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 effective and well led care and was in breach of regulation 9 and 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 C M Desai Limited – Thurncourt on our website www.cqc.org.uk.
As part of this inspection we asked:
• Is it effective?
• 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 (requirement notice only). We then inspect again after a reasonable interval, focusing on the area(s) where improvement was required.
Our findings were:
Are services effective?
We found this practice was providing effective care in accordance with the relevant regulations.
The provider had made improvements in relation to the regulatory breaches we found at our inspection on 20 November 2018.
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 20 November 2018.
Background
C M Desai Limited - Thurncourt is in Leicester and provides NHS and private treatment for adults and children.
There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available at the front of the premises.
The dental team includes three dentists, one dental nurse and one trainee dental nurse. Practice administrative duties are shared between the two principal dentists. The practice has one treatment room.
The practice is owned by a company 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 managers at C M Desai Limited – Thurncourt are the two principal dentists.
During the inspection we spoke with two dentists, one dental nurse and the trainee dental nurse. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open: Monday, Wednesday and Thursday from 9.30am to 12pm, Tuesday and Friday from 1.30pm to 4pm.
Our key findings were:
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The provider demonstrated their commitment to the improvement of governance arrangements.
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We found significant improvements to detail recorded by clinicians in patients’ records.
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Staff demonstrated their knowledge and understanding of the Mental Capacity Act 2005.
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Learning outcomes were identified when incidents were reported and investigated.
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Audit was being used as a tool to drive improvement.
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Policies had been implemented that were specific to the practice.
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A system had been established for the receipt and action of patient safety and medicines safety alerts.
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Risk assessments had been undertaken where required and were specific to the practice operations.
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A computerised patient record system had been implemented; this ensured that information contained in records was legible.
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Appropriate arrangements were in place regarding the disposal of out of date medicines.
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The practice had access to an X-ray viewer to examine radiographs.
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The provider had reviewed access arrangements for patients and improvements were made as a result.