Updated 18 March 2022
We undertook a follow up focused inspection of Secrets Spa Limited on 9 February 2022. 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 Secrets Spa Limited on 12 October 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 safe or well led care and was in breach of regulations 12 and 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 Secrets Spa Limited dental practice on our website www.cqc.org.uk.
As part of this inspection we asked:
• Is it safe?
• Is it well-led?
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 12 October 2021.
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 12 October 2021.
Background
Secrets Spa Limited is in Southport and provides private dental care and treatment for adults and children.
There is a ramp at the front entrance of the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for people with disabilities, are available directly outside the practice with additional street parking nearby.
The dental team includes two dentists, two dental nurses, a practice manager and a receptionist. The practice has two dental treatment rooms and a third treatment room for aesthetic services.
The practice is owned by a company and as a condition of registration must have a person registered with the CQC as the registered manager. Registered managers 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 registered manager at Secrets Spa Limited is the practice manager.
During the inspection we spoke with the practice owner, one dentist, one dental nurse, the 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 to Friday 8.30 am to 5pm
There were areas where the provider could make improvements. They should:
- 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 PHE-CRCE-023 on the safe use of Hand-held Dental X-ray Equipment.
- Take action to implement any recommendations in the practice's fire safety risk assessment and ensure ongoing fire safety management is effective.
- Take action to ensure audits have documented learning points and the resulting improvements can be demonstrated.