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The Chiswick Street Dental Practice

Inspection Summary


Overall summary & rating

Updated 11 July 2017

We carried out this desk based follow up inspection on 27 June 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We carried out an announced comprehensive inspection at the Chiswick Street Dental surgery on 7 December 2016 and at this time a breach of a legal requirement was found. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for The Chiswick Street Dental Practice on our website at cqc.org.uk

After the comprehensive inspection the practice wrote to us and told us that they would take action to meet the following legal requirements set out under the Health and Social Care Act (HSCA) 2008: Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 Safe Care and treatment; Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, Good Governance and Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 Fit and proper persons employed.

The practice was contacted and a request was made for them to submit evidence to demonstrate that they had made the necessary improvements and were now meeting the regulation identified as being breached at the last inspection. The practice’s action plan and a range of information was submitted by the practice and reviewed by a CQC inspector.

Our findings were:

Are services safe?

We found that this practice was now providing safe in accordance with the relevant regulations. The improvements needed had been made.

Are services well-led?

We found that this practice was now providing well-led care in accordance with the relevant regulations. The improvements needed had been made.

Background

Established in 2011, The Chiswick Street Dental practice is located in a grade 2 listed building and provides treatment to patients of all ages who fund their own care. There are two treatment rooms, a decontamination room for sterilising dental instruments, a staff room/kitchen and a general office. Access for wheelchair users or pushchairs is possible from a side ground floor entrance. There is a spacious reception and a waiting area on both floors of the premises.

The practice is open Monday, Tuesday, Thursday and Friday 08.30 -17.30 and Saturdays from 9.00 – 12.30. The practice is closed on a Wednesday.

The dental team is comprised of the principal dentist, three dental nurses, two part-time dental hygienists and one receptionist. There is no designated practice manager.

The practice provides general dentistry.

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 legionella risk assessment had been reviewed and learning actions had been completed. The practice now checked and recorded monthly water temperatures to identify if there may be an increased risk of legionella.
  • Staff had completed a GDC study day which included decontamination processes. We were sent confirmation to show the lead nurse was booked on to a lead decontamination course.
  • The practice had completed an infection control and prevention audit using a recognised tool. They attained an overall score of 93%.
  • Copies of test certificates for the autoclave were available and validation tests were now in place to ensure that the equipment was working properly.
  • All clinical waste was removed correctly supported by a waste removal contract.
  • X-ray audits had been undertaken and learning outcomes had been identified. Staff had undertaken a course on radiography.
  • An AED has been purchased for the use in medical emergencies and staff had been trained on its use.
  • The practice has now subscribed to receive MHRA updates.
  • Recruitment protocols had been updated and personal files amended to ensure information stored was in line with regulation.

Inspection areas

Safe

No action required

Updated 11 July 2017

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

Following the last inspection the practice had had introduced systems and processes to provide safe care and treatment.

The practice’s infection control procedures and protocols fully complied with nationally recognised guidelines.

Gypsum waste generated from a dental laboratory was disposed of in accordance with relevant regulations.

Staff were qualified for their roles and the practice completed essential recruitment checks.

The practice had suitable arrangements for dealing with medical and other emergencies.

Effective

No action required

Updated 11 July 2017

Caring

No action required

Updated 11 July 2017

Responsive

No action required

Updated 11 July 2017

Well-led

No action required

Updated 11 July 2017

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

We found there were support systems in place to ensure the smooth running of the practice which was the responsibility of the principal dentist.

The provider could demonstrate that audits of various aspects of the service were undertaken at regular intervals to help improve the quality of service. Audits did have documented learning points and the resulting improvements demonstrated.