Archived: Mrs Shirley West

We carried out this announced inspection on 12 February 2021 under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to follow up on concerns we identified during a Transitional Regulatory monitoring call on 9 February 2021 and 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 Care Quality Commission (CQC) inspector who was supported by a CQC specialist dental adviser.

To consider the concerns we received we asked the following questions

• Is it safe?

• 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 this practice was not providing safe care in accordance with the relevant regulations.

Are services well-led?

We found this practice was not providing well-led care in accordance with the relevant regulations.

Background

Mrs Shirley West is in the London Borough of Enfield and provides private dental care and treatment for adults and children.

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.

Our key findings were:

• The provider had ineffective infection control procedures to reduce the risk of infections including arrangements for the management of the COVID-19 virus.
• The provider had ineffective systems to help them manage risk to patients and staff. Risk assessments were not carried out, equipment was not tested or serviced as required and there were ineffective systems to monitor procedures in relation to the use and disposal of single use dental items and dental materials.
• The provider had ineffective leadership to support a culture of openness and continuous improvement.
• There were ineffective governance systems to monitor the day to day running of the practice.

We identified regulations the provider was not complying with. They must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with

the fundamental standards of care.

We are considering enforcement action in relation to the regulatory breaches identified. We will report further when any enforcement action is concluded.

Full details of the regulations the provider is not meeting are at the end of this report.