Updated 17 October 2018
We undertook a focused inspection of Bilborough dental practice on 21 September 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 Bilborough dental practice on 30 May 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 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 Bilborough dental practice 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 breach we found at our inspection on 30 May 2018.
Background
Bilborough Dental Practice is in Nottingham and provides mainly NHS dental treatment to both adults and children.
There is level access into the practice with a sliding automatic door. This is particularly of benefit for people who use wheelchairs and those with pushchairs. Car parking spaces, including spaces for blue badge holders, are available in the practice car park.
The dental team includes three dentists, one qualified dental nurse, two trainee dental nurses, and one practice manager. The practice has three treatment rooms, two on the ground floor.
The practice is owned by a company and as a condition of registration must have a person registered with the Care Quality Commission (CQC) 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. At the time of the inspection the practice manager was awaiting their interview with CQC to become the registered manager.
On the day of inspection, we received feedback from 16 patients.
During the inspection we spoke with the practice manager and an area manager representing the provider. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open: Monday: 8.30am to 5:30pm, Tuesday: 8am to 8pm, Wednesday: 8.30am to 5:30pm, Thursday: 8am to 8pm and Friday: 8.30am to 5:30pm, Saturday: 9am to 1pm. The practice is closed on Sunday.
Our key findings were:
- The provider had reviewed the systems and processes for completing audits within the practice, particularly in respect of infection control, dental care records and radiography.
- The practice was holding regular staff meetings and recording the outcome of those meetings.
- The provider had reviewed the way in which incidents related to the duty of candour were managed.
- The practice had begun a process to ensure all staff members had an appraisal of their performance by the practice manager.
- The provider was in the process of ensuring there was a registered manager at the practice. The practice manager had an interview scheduled with the Care Quality Commission to become the registered manager of the service.