12 April 2017
During an inspection looking at part of the service
We carried out an announced comprehensive inspection at JM Worsley Dental surgery on 20 October 2017 and at this time a breach of a legal requirement was 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 under the Health and Social Care Act (HSCA) 2008: Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, Good Governance
On 12 April 2017 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 on 20 October 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 JM Worsley Dental Surgery on our website at cqc.org.uk
Our findings were:
We found that this practice was now providing well-led care in accordance with the relevant regulations. The improvements needed had been made.
Background
The practice offers private primary care dentistry to both adult patients and children. The practice is open Monday to Friday 9.30am - 5.30pm.
There are three dentists, two hygiene therapists, one hygienist, three qualified dental nurses, two trainee dental nurses and a receptionist.
The principal dentist is the registered provider. A registered provider is registered with the Care Quality Commission to manage the service. Registered providers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is run.
Our key findings were:
- The practice had completed a Legionella Risk Assessment in October 2016.
- The practice had completed audits for disability access, fire safety compliance and health and safety in October 2016.
- An Infection Prevention audit was completed on 25 October 2016 with the practice achieving 98% compliance.
- The electrical safety assessment of the building and a gas safety certificate were completed in December 2016.
The practice had also acted upon other recommendations:
- The practice was now registered with the appropriate bodies to receive patient safety and recall alerts
- The x-ray file had been updated to record the names of the Radiation Protection Advisor (RPA) and the Radiation Protection Supervisor (RPS) for the practice.
- The practice manager has developed an audit and equipment service calendar.