13 January 2020
During an inspection looking at part of the service
We undertook a follow up desk-based review of Combe Road Dental Surgery on 13 October 2020. This review was carried out to examine 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 review was led by a CQC inspector.
We undertook a comprehensive inspection of Combe Road Dental Surgery on 14 January 2020 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 and was in breach of regulation 17 and Regulation 19 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 Combe Road Dental Surgery on our website .
As part of this review we asked:
- 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 review again after a reasonable interval, focusing on the areas where improvement was required.
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 14 January 2020.
Background
Combe Road Dental is in Portishead, Bristol and provides private dental care and treatment for adults and children.
There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including parking for blue badge holders, are available near the practice.
The dental team includes one visiting specialist oral surgeon, three dentists, seven dental nurses (including an apprentice dental nurse), two dental hygienists, one dental technician, two receptionists and one practice manager. The practice has three treatment rooms.
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.
The practice is open:
Monday from 9am to 7pm
Tuesday, Thursday and Friday from 9am to 5pm
Wednesday from 9am to 8pm
Saturday from 9am to 1pm
Our key findings were :
The provider had made significant improvements to the management of the service. These included:
- The provider had ensured infection prevention and control procedures, protocols and risk assessments had been reviewed and shared with staff.
- Equipment validation documents were recorded and made readily available.
- An effective system for identifying and disposing of out-of-date materials in treatment rooms had been implemented.
- Dental care records were completed in accordance with the Faculty of General Dental Practice (FGDP) guidance.
- Servicing of x-ray equipment had been completed annually.
- Fire safety management processes were in place.
- Referral monitoring logs had been implemented.
- Staff training oversight and monitoring had been implemented.
- Policies, protocols and risk assessments had been reviewed and shared with staff.
- Audits and resulting action plans had been completed for record keeping, radiography, disability access and infection prevention and control.
- Recruitment procedures had been reviewed and a supporting policy and checklists were implemented. However, the practice did not hold all documents required in accordance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Schedule 3) for one staff member.
These improvements provided a sound footing for the ongoing development of effective governance arrangements at the practice.
There were areas where the provider could make improvements. They should:
- Implement audits for prescribing of antibiotic medicines taking into account the guidance provided by the Faculty of General Dental Practice.
- Improve the practice's recruitment procedures to ensure accurate, complete and detailed records are maintained for all staff.