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Rotherham Road Dental Practice

Inspection Summary


Overall summary & rating

Updated 25 July 2017

We carried out an announced comprehensive inspection of this practice on 22 November 2016. A breach of legal requirement was found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to Regulations 12 of the HSCA (RA) Regulations 2014 Safe Care and Treatment and Regulation 17 of the HSCA (RA) Regulations 2014 Good Governance.

You can read our report of that inspection by selecting the 'all reports' link for Rotherham Road Dental Practice on our website www.cqc.org.uk.

We carried out a focused inspection of Rotherham Road Dental Practice on 29 June 2017.This was to follow up on actions we asked the provider to take after our announced comprehensive inspection. During the inspection on 22 November 2016 we identified that the provider must improve recruitment checks and training for staff with regard to completing disclosing and barring service checks, hepatitis B immunity checks, safeguarding training and Mental Capacity Act training. The provider must improve safety checks with regard to completing risk assessments for health and safety, legionella, sharps and fire safety. The provider must ensure equipment servicing and maintenance was completed in line with manufacturer’s guidance and that assess the need for a defibrillator. In addition we identified that the provider must ensure a system was in place to identify and record significant events and regular audits are undertaken in line with recommended guidance with regards to infection control and radiography.

We reviewed the action plan supplied by the practice following the inspection in January 2017. We undertook a focused inspection on 29 June 2017 and spoke with the principal dentist, the trainee practice manager, the qualified dental nurse and the receptionist. We looked at additional evidence of the improvements made. We looked at practice policies and procedures and other records about how the service is managed.

Our findings were:

Are services safe?

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

Are services well-led?

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

Background

Rotherham Road Dental Practice is a general dental practice is the Holbrooks area of Coventry. It is also known as Holbrook Dental Surgery.

The practice provides general dental treatment to adults and children funded mostly by the NHS, or privately.

There is a level access throughout the practice for people who use wheelchairs and pushchairs with all rooms being on the ground floor. The practice has a waiting room, reception area, patient toilet, staff toilet, staff kitchen, two treatment rooms (although only one is in use) and a decontamination room.

The dental team includes a principal dentist, a trainee dental nurse, a qualified dental nurse, a receptionist and a trainee practice manager.

The principal dentist is registered with the Care Quality Commission (CQC) as an individual. Like registered providers, they are ‘registered persons’. Registered persons 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 practice is open:

Monday, Tuesday, Thursday and Friday - 9am to 5.30pm

Wednesday - 9am to 8pm

Saturday - 9am to 1pm

Our key findings were:

  • Improvements were seen in all areas where concerns had been highlighted in the comprehensive inspection.

  • The practice had systems to help them manage risk. Health and safety, legionella, sharps and a fire risk assessment had been completed and actions carried out.

  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were all in date and available including an automated external defibrillator.

  • Pre-employment checks and mandatory training were carried out in line with regulation.

  • Effective systems had been developed to identify and ensure the servicing of all equipment.

  • Clinical audit was used effectively to highlight areas where improvements could be made.

  • Policies to aid the smooth running of the service had been developed and signed by staff since our last visit to the practice.

At our announced inspection on 22 November 2016, there were areas we identified where the provider could make improvements. During our follow up inspection on 29 June 2017 improvements were seen in the following areas:

  • Appropriate documentation pertaining to substances hazardous to health was kept in the practice.

  • The practice was now monitoring and recording the temperature of the refrigerator used to store temperature sensitive medicines and dental materials.

  • Prescription pads security in the practice had been reviewed and systems were in place to track and monitor their use.

  • The principal dentist monitored the gum health of patients, and was using the nationally recognised scoring system. The principal dentist was now clear on the nationally recognised guidance in the care and treatment of patients and was applying the principles of the guidance in their treatment of patients.
Inspection areas

Safe

No action required

Updated 25 July 2017

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

Improvements were noted in the way the practice managed emergency equipment and medicines and risk assessments.

  • The practice had reviewed their systems for checking emergency equipment and medicines and had implemented new processes. The practice had replaced all the equipment previously noted to have been out of date and had purchased an automated external defibrillator.

  • The practice completed risk assessments in relation to health and safety, X-ray, legionella, sharps and fire, detailing and undertaking any relevant actions as required.

  • All of the improvements above were discussed at a practice meeting and minuted for all team members’ awareness.

Effective

No action required

Updated 25 July 2017

Caring

No action required

Updated 25 July 2017

Responsive

No action required

Updated 25 July 2017

Well-led

No action required

Updated 25 July 2017

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

Improvements were noted in the way the practice managed audits, recruitment checks, staff training, equipment maintenance, and policies.

  • The practice monitored clinical areas of their work through audit such as X-ray and infection control to help them improve and learn.

  • Recruitment processes had been amended and all staff had completed a disclosing and barring service check and Hepatitis B immunity check.

  • The provider had oversight of staff training and all staff had completed mandatory training including level two safeguarding adults and mental capacity act training.

  • Effective systems were established to identify and ensure the servicing needs of all equipment.

  • Policies had been developed in relation to safeguarding adults, incident reporting and health and safety.

  • All of the improvements above were discussed at a practice meeting and minuted for all team members’ awareness.