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Inspection carried out on 20 April 2018

During an inspection looking at part of the service

We carried out an announced follow-up inspection at Copley Dental Care on 20 April 2018.

We had undertaken an announced comprehensive inspection of this service on the 26 October 2017 as part of our regulatory functions where a breach of legal requirements was found.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to the breach. This report only covers our findings in relation to those requirements. We checked whether they had followed their action plan to confirm that they now met the legal requirements.

We reviewed the practice against one of the five questions we ask about services: are the services well led? You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Copley Dental Care on our website at www.cqc.org.uk.

We revisited Copley Dental Care as part of this review and checked whether they now met the legal requirements. We carried out this announced inspection on 20 April 2018 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.

• Is it well-led?

This question forms the framework for the areas we look at during the inspection.

Our findings were:

Are services well-led?

We found that this practice was providing well-led care in accordance with the relevant regulations.

Background

Copley Dental Care is near Halifax and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and pushchairs. The practice has a small dedicated car park.

The dental team includes one dentist and three dental nurses (two of whom are trainees).

The practice has two treatment rooms.

The practice is owned by an individual who is the principal dentist there. 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 two dental nurses. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Tuesday to Friday from 10:00am to 6:00pm

Our key findings were:

  • Improvements had been made to the process for reducing the risks associated with fire and sharps.
  • Improvements had been made to the process for environmental cleaning.
  • Improvements had been made to the recruitment process.

Inspection carried out on 26 October 2017

During a routine inspection

We carried out this announced inspection on 26 October 2017 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.

We told the NHS England area team and Healthwatch that we were inspecting the practice. They did not provide any information of concern.

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 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

Copley Dental Care is near Halifax and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and pushchairs. The practice has a small dedicated car park.

The dental team includes one dentist, three dental nurses (two of whom are trainees), one dental hygiene therapist and one receptionist. The practice has two treatment rooms.

The practice is owned by an individual who is the principal dentist there. 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.

On the day of inspection we collected 30 CQC comment cards filled in by patients. This information gave us a positive view of the practice.

During the inspection we spoke with the dentist, two dental nurses and the dental hygiene therapist. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Tuesday to Friday from 10:00am to 6:00pm

Our key findings were:

  • The practice was clean and well maintained.
  • The practice had infection control procedures which reflected published guidance. The practice did not have a cleaning schedule for environmental cleaning.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
  • The practice’s process for managing risk could be improved with respect to fire and sharps.
  • The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
  • Improvements could be made to the recruitment process with respect to seeking Disclosure and Barring Service (DBS) checks.
  • The clinical staff provided patients’ care and treatment in line with current guidelines. Dental care records lacked sufficient detail especially with regards to consent.
  • Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • The appointment system met patients’ needs.
  • The practice had effective leadership. Staff felt involved and supported and worked well as a team.
  • The practice asked patients for feedback about the services they provided.
  • The practice had a complaints policy in place.
  • Improvements could be made to the process for carrying out the infection prevention and control audit.

We identified regulations that were not being met and the provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

There were areas where the provider could make improvements and should:

  • Review the storage of dental care products and medicines requiring refrigeration to ensure they are stored in line with the manufacturer’s guidance and the fridge temperature is monitored and recorded.
  • Review the practice’s protocols for recording in the patients’ dental care records a report for the X-ray and quality of the X-ray giving due regard to the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2000.
  • Review the practice's protocols for completion of dental records giving due regard to guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.