Alan Lam Family Dental Practice Ltd

We undertook a follow up inspection of 6 January 2020. 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 Alan Lam Family Dental Practice Ltd on 16 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 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 Alan Lam Family Dental Practice Ltd 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. 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 breaches we found at our inspection on 16 July 2019.

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 16 July 2019.

Background

Alan Lam Family Dental Practice is in Chester le Street and provides 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 two dentists and three dental nurse/receptionists and a practice manager. The practice has two treatment rooms.

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 manager at the practice is the senior partner.

During the inspection we spoke with two dentists, one dental nurse/receptionist 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 and Thursday 8:45am -6pm, Tuesday 9am-7pm and Friday 8am-3pm

Our key findings were:

• Improvements had been made to infection control procedures, staff understanding of decontamination procedures had improved.
• The decontamination room met relevant guidance.

• Emergency medicines and life-saving equipment were in line with Resuscitation Council UK standards.
• Improvements had been made to the storage of clinical waste and management of sharps.
• Improvements to fire, electrical and gas safety had been made.
• Effective monitoring of systems regarding Legionella were in place. The designated lead had completed legionella training.

We carried out this announced inspection on 16 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 not 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

Alan Lam Family Dental Practice is in Chester le Street and provides 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 two dentists and three dental nurse/receptionists. The practice has two treatment rooms.

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 manager at Alan Lam Family Dental Practice is the practice owner who we were told is no longer in day to day contact with the practice. We advised the role of registered manager of the organisation may be better placed with the principal dentist at the practice who is presently in day to day control.

During the inspection we spoke with two dentists and two dental nurse/receptionists. 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 and the decontamination room to meet relevant guidance.
• 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.
• 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, fire and gas safety.
• 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.
• 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:

• Ensure care and treatment is provided in a safe way to patients.

• 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.