18 March 2021
During an inspection looking at part of the service
We undertook a follow up desk-based review of Spires dental practice on 18 March 2021. 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.
We undertook a comprehensive inspection of Spires Dental Practice on 12 February 2020 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 safe and well led care and was in breach of regulation 12 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 Spires Dental Practice on our website www.cqc.org.uk.
As part of this inspection we asked: Remove as appropriate:
• Is it safe?
• 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 areas where improvement was required.
Our findings were:
Are services safe?
We found this practice was providing safe care in accordance with the relevant regulations.
The provider had made improvements in relation to the regulatory breach we found at our inspection on 12 February 2020.
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 12 February 2020.
Background
Spires Dental Practice is in Lichfield, Staffordshire and provides private dental care and treatment for adults and children.
There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for people with disabilities, are available in pay and display car parks near the practice, some time restricted parking is available on the road opposite the practice.
The dental team includes two dentists, five dental nurses, including a lead nurse and a practice co-ordinator, two dental hygiene therapists and one receptionist. The practice has three treatment rooms.
The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.
During the inspection we checked that the registered provider’s action plan had been implemented. We reviewed a range of documents provided by the registered provider.
The practice is open: Monday from 9am to 5pm, Tuesday 9am to 5pm, Wednesday 9am to 7pm, Thursday 9am to 5pm, Friday 8.30am to 4.30pm, Saturday 8am to 12pm.
Our key findings were:
Improvements had been made to the storage and management of medicines, including those to be used in a medical emergency. Monitoring checks demonstrated that medicines were correctly stored, available and within their expiry date. Stock control systems were in place for medicines to be dispensed at the practice. Appropriate dispensing information was recorded on medicines’ dispensing labels.
Fire safety systems and processes had been reviewed. Fire safety equipment was subject to routine service and maintenance. Fire drills were completed by staff. An external professional has been booked to complete a fire risk assessment.
The practice had implemented systems and processes for learning and continuous improvement including developing the practice’s protocols for auditing patient dental care records. Staff had completed update training regarding infection prevention and control and safeguarding children and vulnerable adults. Further action should be taken to ensure staff are trained to the appropriate level.
Improvements had been made to assessment and management of risks. Control of Substances Hazardous to Health risk assessments had been completed. Sharps management procedures had been improved and some action had been taken regarding the secure storage of clinical waste, but further action was required.
Improvements had been made to recruitment processes, although further action is required.
There were areas where the provider could make improvements. They should:
Take action to implement any recommendations in the practice's fire safety risk assessment and ensure ongoing fire safety management is effective.
Improve the practice's waste handling protocols to ensure waste is segregated and disposed of in compliance with the relevant regulations and taking into account the guidance issued in the Health Technical Memorandum 07-01.
Take action to ensure that all the staff have received training, to an appropriate level, in the safeguarding of children and vulnerable adults.
Implement an effective recruitment procedure to ensure that appropriate checks are completed prior to new staff commencing employment at the practice.