Updated 7 September 2018
We undertook a follow up focused inspection of Irby Dental Surgery on 8 August 2018. This inspection was carried out to review in detail the actions taken by the provider to improve the quality of care, and to confirm that the practice was now meeting the legal requirements.
The inspection was led by a CQC inspector who was supported by a specialist dental adviser.
We undertook a comprehensive inspection of Irby Dental Surgery on 11 April 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We found the provider was not providing well-led care, and was in breach of Regulation 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 Irby Dental Surgery on our website www.cqc.org.uk.
When one or more of the five questions are not met we require the provider to make improvements. We then inspect again after a reasonable interval, focusing on the areas in which improvement was necessary.
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 sufficient improvements in relation to the regulatory breach we identified at our inspection on 11 April 2018.
Background
Irby Dental Surgery is near the centre of Irby and provides private dental care and treatment for adults and children.
There is level access to the practice for people who use wheelchairs and for those with pushchairs. Car parking spaces are available at the practice.
The dental team includes two dentists, two dental hygiene therapists and three dental nurses, one of whom is the 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 Irby Dental Surgery is the principal dentist.
During the inspection we spoke with the principal dentist, a dental nurse, 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 to Friday 9.00am to 5.30pm.
Our key findings were:
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The provider had improved their systems and processes to enable them to assess, monitor and improve the quality and safety of the services being provided, for example, we saw infection control systems were now operating more effectively.
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We saw that the provider’s systems and processes for enabling them to identify and reduce risks at the practice were now operating more effectively, for example, in relation to the control of the practice’s water systems.
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The provider had improved systems and processes to enable them to evaluate and improve their practice and had put further arrangements in place to encourage patients to provide feedback.
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We found that the system for monitoring staff training had improved but was not operating effectively.
There were areas where the provider could make improvements. They should:
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Review the practice's protocols and procedures to ensure staff are up to date with their training and continuing professional development.
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Review the practice’s protocols to ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.