Updated 22 August 2019
We undertook a focused inspection of Aylestone House Dental Practice on 3 July 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 Aylestone House Dental Practice on 3 December 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 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 Aylestone House dental practice 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 3 December 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 3 December 2018.
Background
Aylestone House Dental Practice is in a suburb of Leicester and provides NHS and (mostly) private treatment to adults and children.
There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces, including for blue badge holders, are available in the practice’s car park at the rear of the premises.
The dental team includes three dentists, three dental nurses, three trainee dental nurses and a practice manager. The practice has three treatment rooms; all are on the ground floor.
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 spoke with one dentist and two dental nurses. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open: Monday from 8.15am to 6.30pm, Tuesday and Thursday from 8.15am to 5.30pm, Wednesday from 8.15am to 5pm, and Friday from 8.15am to 2.30pm.
Our key findings were:
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Improvements had been made to the detail recorded in patients’ dental care records overall. We also noted some areas where further detail was required.
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The dentist demonstrated understanding of the Mental Capacity Act 2005.
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Procedures had been implemented for significant event/untoward incident reporting and staff discussed these when they occurred.
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Audit processes had been strengthened; we also noted some areas for further review.
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Policy required had been implemented.
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Staff had received appraisals.
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Systems and processes were established to enable the provider to comply with legislative requirements in respect of staff recruitment.
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A system had been implemented for the review and action of patient safety alerts.
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We saw evidence that risks were assessed and managed appropriately.
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The provider had taken into account guidance provided by the Faculty of General Dental Practice regarding the prescribing of antibiotic medicines.
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The provider had reviewed and taken some account of the ‘Guidelines for the Delivery of a Domiciliary Oral Healthcare Service’ published by British Society for Disability and Oral Health.
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Monitoring was in place for stocks of medicine and equipment to ensure that the practice identified, disposed and replenished out-of-date stock.
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The provider had reviewed its responsibilities to take into account the needs of patients with disabilities in line with the Equality Act 2010.