Updated 13 August 2018
We undertook a follow up focused inspection of Dr Philip Stemmer on 11 July 2018. 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 Dr Philip Stemmer on 22 November 2017 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 well led care in accordance with the relevant regulations 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 Dr Philip Stemmer on our website www.cqc.org.uk.
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 area where improvement was required.
As part of this inspection we asked:
• Is it well-led?
Our findings were:
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 22 November 2018.
Background
Dr Philip Stemmer is located in Westminster and provides private treatment to patients of all ages.
The dental team includes a dentist and a dental nurse.
The practice is owned by an individual who is the principal dentist. 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 the dentist and the dental nurse. We also spoke with a compliance consultant that the provider had employed. We looked at practice policies and procedures and other records about how the service is managed.
Our key findings were:
- The practice had systems and processes to ensure good governance in accordance with the fundamental standards of care, including policies, procedures, risk assessments and quality assurance processes.
- The practice received and responded to patient safety alerts, recalls and rapid response reports issued from the Medicines and Healthcare Products Regulatory Agency (MHRA).
- The practice had a system in place for investigating and reviewing incidents or significant events with a view to preventing further occurrences and ensuring that improvements are made as a result.
- The practice had safeguarding policies that covered both adult and children.
- The practice had some understanding of the requirements of the Mental Capacity Act (MCA) 2005 but further improvements were still required.
- The practice had policies and procedures in place for obtaining patient consent to care and treatment.
- The practice had complaints policies and procedure for identifying, receiving, recording, handling and responding to complaints by service users. Staff were clear who were responsible for dealing with complaints.
- The practice had a recruitment policy and had undertaken essential recruitment checks for staff.
There were areas where the provider could make improvements. They should:
- Review the practice’s audit protocols to ensure audits of various aspects of the service, such as radiography have documented learning points that are shared with all relevant staff and the resulting improvements can be demonstrated.