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Inspection Summary

Overall summary & rating

Updated 21 January 2020

We undertook a focused inspection of Stoke Lane Dentistry on 19 November 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 specialist dental adviser.

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. You can read our report of that inspection by selecting the 'all reports' link for Stoke Lane Dentistry on our website

As part of this inspection we asked:

• Is it well-led?

At the last inspection we found the well-led key question was not met and we required the service to make improvements. We then inspected 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 not providing well-led care in accordance with the relevant regulations.

The provider had made improvements since the last inspection to put right the shortfalls we had identified. However, we found at our inspection on 19 November 2019 that there were some areas that still required improvement.


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

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

The dental team includes three dentists; the principal dentist, a locum and a visiting dentist who carries out implant work, agency dental nurses, two dental hygienists 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 two dentists and the business 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:

  • The systems to manage staff training and support had improved.
  • The systems for managing risks to health and safety, fire safety, substances hazardous to health, safer sharps, incidents, X-rays, infection control, legionella, medical emergencies and prescriptions had improved.
  • The provider had improved the systems in place to ensure clinical staff had received the vaccination to protect them against the Hepatitis B virus, and that the effectiveness of the vaccination was checked.
  • The systems to ensure policies and procedures were up to date with current guidelines had improved.
  • The system for managing complaints had improved.
  • The system to ensure the Accessible Information Standard was complied with had improved.
  • The systems in place to manage how staff were safely recruited had improved. Although there were still some improvements to be made.
  • The system for monitoring referrals still needed improvement.
  • The systems in place to ensure patient dental care records included the necessary information required improvement.
  • The systems in place to manage and record information on how antibiotics were prescribed according to guidelines needed to be improved.

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 was not meeting are at the end of this report.

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

  • Take action to ensure clinicians record in the patients’ dental care records or elsewhere the reason for taking X-rays, a report on the findings and the quality of the image in compliance with Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment.
Inspection areas


No action required

Updated 5 September 2019


No action required

Updated 5 September 2019


No action required

Updated 5 September 2019


No action required

Updated 5 September 2019


Improvements required

Updated 21 January 2020