Updated 20 March 2020
We undertook a follow up desk-based inspection of Spilsby Dental Surgery on 13 February 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 inspection was led by a CQC inspector.
We undertook a comprehensive inspection of Spilsby Dental Surgery on 17 June 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 regulation 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 Spilsby Dental Surgery 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 (requirement notice only). We then inspect again after a reasonable interval, focusing on the area(s) 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 17 June 2019.
Background
The practice is in the centre of Spilsby, a village in Lincolnshire. It provides NHS and private treatment to adults and children.
The practice is in a grade two listed building which has limitations on modernisations that can be made. There are two treatment rooms, both on ground floor level, a decontamination room, a reception area, waiting room, office, staff toilet and patient toilet facility. There is also a staff room on the first floor of the practice. Access to the building is through a side alley. Patients with limited mobility or those who use wheelchairs are assisted by staff members to open the door to the practice.
There is no car parking available on site; there is a pay and display car park with spaces for blue badge holders within close proximity of the premises.
The dental team includes: one dentist, one dental nurse, one trainee dental nurse, one dental hygienist and one receptionist. The current owner at the time of our follow up inspection of the practice, is a qualified dentist who oversees the management and administrative functions.
At the time of our inspection, the practice was owned by an individual. 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. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open: Monday to Thursday from 8.30am to 5pm. It closes between 1pm and 2pm on those days during lunchtimes.
Our key findings were:
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Policies had been subject to update and were computerised. Staff had access to policies and details for lead contacts were displayed in the practice for staff to refer to.
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A process for undertaking staff appraisals had been implemented since our previous inspection.
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A monitoring log was in place to enable more effective tracking of staff’s continuing professional development and training.
- Audit activity and its resulting outcomes had been subject to discussion by staff in practice meetings.
- The provider had reviewed the requirements for legislative checks if new staff were recruited. This included contact with the agency that had been used when temporary staff had been supplied to seek assurance.
- Areas of risk had been subject to further review such as the use of sharps and the security of prescription pads.
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The dental chair that contained tears had been repaired with new upholstery.
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The Mental Capacity Act 2005 and Gillick competence had been subject to discussion amongst the team.
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Patient safety alerts were being received and actioned, if appropriate.