The Care Quality Commission
  • Dentist
  • Dentist

Delahays Dental Practice

2 Delahays Drive, Hale, Altrincham, Cheshire, WA15 8DP (0161) 980 5019

Provided and run by:
Mr Neil Mclean

All Inspections

12 November 2021

During an inspection looking at part of the service

We undertook a follow up focused inspection of Delahays Dental Practice on 12 November 2021. 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 specialist dental adviser.

We undertook a focused follow inspection of Delahays Dental Practice on 19 February 2021 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 Delahays Dental Practice 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. We then inspect again after a reasonable interval, focusing on the areas where improvement was required.

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 breaches we found at our inspection on 19 February 2021.

Background

Delahays Dental Practice is in Hale, Cheshire and provides NHS and private dental treatment for adults and children.

The practice is located on the first floor. Access is not possible for people who use wheelchairs. On street parking is available near the practice.

The dental team includes two dentists, three dental nurses, a dental hygienist, and two receptionists. The team is supported by a finance and administrative manager and an administrative assistant. 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 principal dentist, three dental nurses and the finance and administrative manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday, Wednesday, Thursday and Friday 9am to 1pm and 2pm to 5.30 pm.

Tuesday 9am to 1pm and 2pm to 4pm.

Our key findings were:

  • The provider had infection control procedures which reflected published guidance.
  • The provider had standard operating procedures in line with national guidance on COVID-19. The systems to screen patients prior to attending could be improved.
  • Staff knew how to deal with emergencies. Emergency medicines and life-saving equipment were available in line with guidance.
  • Systems were in place to help them identify and manage risk to patients and staff.
  • Governance systems introduced after the previous inspection were complete and more established.
  • Staff recruitment procedures had been improved in line with current legislation.
  • The clinical staff provided patients’ care and treatment in line with current guidelines. The documentation of this had improved and would benefit from ingoing improvement.
  • Improvements to be made to ensure all clinicians follow guidance on the assessment of, and promoting the maintenance of good oral health.

There were areas where the provider could make improvements. They should:

  • Take action to ensure the clinicians carry out patient assessments and ensure they are in compliance with current legislation and take into account relevant nationally recognised evidence-based guidance. In particular, guidelines issued by the Department of Health publication ‘Delivering better oral health: an evidence-based toolkit for prevention’ when promoting the maintenance of good oral health.

19 February 2021

During an inspection looking at part of the service

We undertook a follow up focused inspection of Delahays Dental Practice on 19 February 2021. 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 specialist dental adviser.

We undertook a comprehensive inspection of Delahays Dental Practice on 4 December 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 safe or well led care and was in breach of regulations 12, 17 and 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 Delahays Dental Practice on our website www.cqc.org.uk.

As part of this inspection we asked: Remove as appropriate:

• Is it safe?

• 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. We then inspect again after a reasonable interval, focusing on the areas where improvement was required.

Our findings were:

Are services safe?

We found this practice was providing safe care in accordance with the relevant regulations.

The provider had made improvements in relation to the regulatory breaches we found at our inspection on 4 December 2019.

Are services well-led?

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

The provider had made improvements in relation to the regulatory breaches. These were insufficient to fully address the shortfalls we found at our inspection on 4 December 2019.

Background

Delahays Dental Practice is in Hale, Cheshire and provides NHS and private dental treatment for adults and children.

The practice is located on the first floor. Access is not possible for people who use wheelchairs. On street parking is available near the practice.

The dental team includes two dentists, three dental nurses, a dental hygienist, and two receptionists. The team is supported by a finance and administrative manager and an administrative assistant. 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 both dentists, three dental nurses and the finance and administrative manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday, Wednesday, Thursday and Friday 9am to 1pm and 2pm to 5.30 pm.

Tuesday 9am to 1pm and 2pm to 4pm.

Our key findings were:

  • The infection control procedures had been reviewed and improved.
  • The provider had implemented standard operating procedures in line with national guidance on COVID-19.
  • Staff knew how to deal with emergencies. Emergency medicines and life-saving equipment were broadly in line with guidance. An item of equipment had passed the expiry date and staff were not aware. Immediate action was however taken by the provider to mitigate the risks.
  • The provider had introduced some systems to help them identify and manage risk to patients and staff. Further improvements were required.
  • The provider had safeguarding processes in place. All staff had received training in safeguarding and understood their responsibilities for safeguarding vulnerable adults and children.
  • Some governance systems had been introduced but were not yet complete or established.
  • Staff recruitment procedures did not reflect current legislation.
  • The clinical staff provided patients’ care and treatment in line with current guidelines. The auditing and documentation of this required improvement.

We identified regulations the provider was not meeting. They must:

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

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

There were areas where the provider could make improvements. They should:

  • Take action to ensure the clinicians take into account the guidelines issued by the Department of Health publication ‘Delivering better oral health: an evidence-based toolkit for prevention’ when promoting the maintenance of good oral health.
  • Take action to implement the recommendation in the practice's fire safety risk assessment to provide staff with fire safety awareness training to ensure ongoing fire safety management is effective.

4 December 2019

During a routine inspection

We carried out this announced inspection on 4 December 2019 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 Care Quality Commission, (CQC), inspector who was supported by a specialist dental adviser.

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

Are services effective?

We found this practice was providing effective care in accordance with the relevant regulations.

Are services caring?

We found this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found this practice was providing responsive 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

Delahays Dental Practice is in Hale, Cheshire and provides NHS and private dental treatment for adults and children. The practice provides an NHS children’s inhalation sedation service.

The practice is located on the first floor. Access is not possible for people who use wheelchairs. On street parking is available near the practice.

The dental team includes two dentists, three dental nurses, a dental hygienist, and two receptionists. The team is supported by a finance and administrative manager and an administrative assistant. The inhalation sedation service is provided by a visiting specialist dentist who attends accompanied by a dental nurse with additional training. 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 45 CQC comment cards filled in by patients and spoke with two other patients.

During the inspection we spoke with three dentists, three dental nurses and a receptionist 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, Wednesday, Thursday and Friday 9am to 1pm and 2pm to 5.30 pm.

Tuesday 9am to 1pm and 2pm to 4pm.

Our key findings were:

  • The practice appeared to be visibly clean, tidy and well-maintained.
  • The infection control procedures should be reviewed.
  • Staff knew how to deal with emergencies. Emergency medicines and life-saving equipment were not in line with guidance. Some items of equipment had passed their expiry date and insufficient amounts of adrenaline was available.
  • The provider did not have systems to help them identify and manage risk to patients and staff.
  • The provider had safeguarding processes in place. Not all staff had received training in safeguarding or understood their responsibilities for safeguarding vulnerable adults and children.
  • Staff recruitment procedures did not reflect current legislation.
  • The clinical staff provided patients’ care and treatment in line with current guidelines. The documentation of this required improvement.
  • Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • Staff provided preventive care and supported patients to ensure better oral health.
  • The appointment system took account of patients’ needs.
  • Staff felt involved and supported and worked as a team.
  • The provider asked staff and patients for feedback about the services they provided.
  • The provider had systems to deal with complaints positively and efficiently.

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.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

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

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.
  • Implement protocols and procedures in relation to the Accessible Information Standard to ensure that that the requirements of this are complied with.
  • Take action to review information governance arrangements are effective. In particular; for post received at the practice.
  • Improve the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment. In particular: Registering the use of X-rays with the Health and Safety Executive.

12 June 2013

During a routine inspection

We walked around the practice and saw that there were two surgeries, a decontamination room, a waiting room reception and toilet. We spoke with eight patients who were attending for treatment. Comments were all positive and included: "They are really friendly." "I am always able to get a convenient appointment." "I am never kept waiting too long." "I feel that I am in safe hands." "I have no difficulty getting an appointment." "They manage to fit me in if I need an appointment." "The service is very good, it is excellent." "They are marvellous."

Staff spoken with had a good understanding of their responsibilities in relation to safeguarding. Staff had attended briefings on child and adult protection.

Patient records were detailed and all the required checks had been carried out. We saw that patients were asked about their general health and had an examination of their mouth, teeth and gums. Patients we spoke with told us: "The dentist always has a good look around my mouth before starting treatment." "He asks if I have been well since the last visit."

We saw that correct practices for the decontamination and sterilisation processes were undertaken as per Health Technical Memorandum (HTM) 01-05 requirements.