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Inspection Summary


Overall summary & rating

Updated 10 December 2020

We undertook a follow up desk-based review of Stoke Lane Dentistry on 23 November 2020. 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 desk top review was carried out by a CQC inspector.

We undertook a comprehensive inspection of Stoke Lane Dentistry on 7 August 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 regulations 19 fit and proper persons employed, 18 staffing and 17 good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

On 19 November 2019 we undertook a focused follow up inspection to review the breaches of regulation found at the inspection on 7 August 2019. We found the provider had made significant improvements with the breaches identified, however, there were still some areas to improve. We found the provider was still not well led and was in breach of regulation 17 good governance.

You can read our reports of these inspections by selecting the 'all reports' link for Stoke Lane Dentistry 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.

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 19 November 2019.

Background

Stoke Lane Dentistry is in Westbury-on-Trym, Bristol and provides NHS and private treatment for adults and children.

There is level access to one treatment room for people who use wheelchairs. There is on-street car parking near the practice.

The dental team includes two dentists, a visiting dentist who carries out implant work, one qualified dental nurse, one trainee dental nurse, one dental hygienist, one dental therapist, a practice manager and three receptionists. The practice has four 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 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 to Friday 9am – 5:30pm

Our key findings were:

  • An effective system had been implemented to centrally monitor urgent or non-urgent patient referrals to ensure they were not lost and acted upon.
  • The provider had an effective system in place to ensure records included monitoring of the quality of the radiograph, justification and findings.
  • Systems were in place to ensure clinicians took into account guidance and legislative requirements for the completion of patient dental care records.
  • There was an effective system in place to recruit staff safely, ensuring legislation guidelines were followed.

Inspection areas

Safe

No action required

Updated 10 December 2020

Effective

No action required

Updated 10 December 2020

Caring

No action required

Updated 10 December 2020

Responsive

No action required

Updated 10 December 2020

Well-led

No action required

Updated 10 December 2020

We found that this practice was providing well led care and was complying with the relevant regulations.

At our previous inspection on 19 November 2019 we judged the provider was not providing well led care and was not complying with the relevant regulations. We told the provider to take action as described in our requirement notice. We carried out a desk top review on 23 November 2020 we found the practice had made the following improvements to comply with regulation 17 good governance:

  • There was an effective system in place to recruit staff safely, ensuring legislation guidelines were followed. A risk assessment had been completed to ensure all information was available for recruited staff and actions if not. There were checklists in place for newly recruited staff.
  • An effective system had been implemented to centrally monitor urgent or non-urgent patient referrals to ensure they were not lost and acted upon. We saw a clear referral protocol for staff to refer to and the system used to monitor referrals.
  • Systems were in place to ensure clinicians took into account guidance and legislative requirements for the completion of patient dental care records. Regular clinical record audits had been carried out and improvement plans had been identified. Further analysis of the audits could be beneficial to ensure all areas of improvement were identified. For example, where it was shown that the clinician had not completed one of the steps to show the rationale for this. Improvements had been made to how patients’ records were managed for patients receiving dental implants. Discussions had been held with the clinician and audits undertaken to ensure patients’ treatment plans were held on their records. There was a process in place to ensure patient consent was recorded for taking photographs and to ensure photographs were held on patient records. An antibiotic prescribing audit had been completed to ensure current guidelines were followed.

The practice had also made further improvements:

  • The provider had an effective system in place to ensure records included monitoring of the quality of the radiograph, justification and findings. We reviewed the provider’s last audit from November 2020, which showed analysis of, where applicable, why the quality of X-ray was below standard.

These improvements showed the provider had taken action to improve the quality of services for patients and comply with regulation 17 good governance.