Updated 31 January 2020
We undertook a focused inspection of Ortho Limited t/a Cheyne Walk Orthodontics on 4 December 2019. 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 second CQC inspector.
We undertook a comprehensive inspection of Ortho Limited t/a Cheyne Walk Orthodontics on 12 March 2019 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 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 Ortho Limited t/a Cheyne Walk Orthodontics on our website www.cqc.org.uk.
As part of this inspection 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 inspect again after a reasonable interval, focusing on the area(s) 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 12 March 2019.
We found this practice was providing well-led care in accordance with the relevant regulations.
Background
Ortho Limited t/a Cheyne Walk Orthodontics is in Northampton, a town in the East Midlands. The practice provides both NHS and private orthodontic treatments to adults and children. Orthodontics is a specialist dental service concerned with the alignment of the teeth and jaws to improve the appearance of the face, the teeth and their function. Orthodontic treatment is provided under NHS referral for children except when the problem falls below the accepted eligibility criteria for NHS treatment. Private treatment is available for these patients as well as adults who require orthodontic treatment. Services of scale and polish are offered to patients as well.
Level access is not available for people who use wheelchairs and those with pushchairs; stepped access is in place at both the front and rear of the building. The premises are situated in a listed building; the potential for extensive modifications to the building is therefore limited. Car parking spaces are available in the practice’s car park at the rear of the building.
The dental team includes two orthodontists, two qualified dentists who work as orthodontic therapists, two dental nurses, one trainee dental nurse, two receptionists and a cleaner.
The practice has four treatment rooms; two are on the ground floor. There is a separate decontamination facility on site.
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 Ortho Limited t/a Cheyne Walk Orthodontics is the practice owner.
During the inspection we spoke with the practice owner. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open: Monday, Tuesday and Wednesday from 9am to 5.30pm, Thursday from 9am to 7pm, Friday from 9am to 5pm and on some Saturdays from 9am to 4pm.
Our key findings were:
- Processes had been implemented to enable the registered person to more effectively monitor staff training requirements.
- Processes established enabled the registered person to ensure that policies were reviewed annually or when required.
- Documentation was available in respect of induction checklists for use when any new staff started working at the practice.
- We saw that staff appraisals took place regularly.
- We saw that action was being taken to mitigate the risk presented by legionella.
- A risk assessment had been completed in respect of staff use of sharps within the practice.
- Systems had improved in relation to recruitment checks for staff.
There were areas where the provider could make improvements. They should:
- Ensure the practice’s arrangements for ensuring good governance and leadership are sustained in the longer term.