Archived: Miss Atena Shirafkan Also known as Lemoge Dental Surgery

We carried out this unannounced focused inspection on 28 June 2022 under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to follow up on concerns raised during a monitoring call on 21 June 2022 and to check whether the registered practice was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a Care Quality Commission, (CQC), inspector who was supported by a specialist dental adviser.

To get to the heart of patients’ experiences of care and treatment,

we usually ask five key questions, however due to the ongoing COVID-19 pandemic and to reduce time spent on site, only the following three questions were asked:

• Is it safe?

• Is it effective?

• Is it well-led?

These questions form the framework for the areas we look at during the inspection.

Our findings were:

• Patients were treated with dignity and respect and staff took care to protect their privacy and personal information.
• Staff provided preventive care and supported patients to ensure better oral health.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• The appointment system took account of patients’ needs.
• The dental clinic had information governance arrangements
• The dental clinic was visibly clean and well-maintained.
• Improvements were required to ensure infection control procedures were in accordance with relevant guidelines.
• Improvements were required to the arrangements for dealing with medical emergencies.
• The practice had ineffective systems to help them manage risk to patients and staff.
• Improvements were needed to the practice safeguarding processes.
• The practice staff recruitment procedures were not in accordance with current legislation.
• There was ineffective leadership and a lack of culture of continuous improvement.

Background

The provider has one practice.

Miss Atena Shirafkan is located in Kilburn in the London Borough of Brent and provides private dental care and treatment for adults and children.

There is level access to the practice for people who use wheelchairs and those with pushchairs.

The dental team includes one dentist, one dental nurse, one trainee dental nurse and a practice manager. The practice has two treatment rooms.

During the inspection we spoke with the dentist and the dental nurses. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Friday 9am to 5pm

We identified regulations the provider was not complying with. They must:

• Ensure care and treatment is provided in a safe way to patients
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed

Full details of the regulation/s the provider was not meeting are at the end of this report.

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

• Implement an effective system for identifying, disposing and replenishing of out-of-date stock.
• Improve the practice's protocols for medicines management and ensure all medicines are stored and dispensed of safely and securely.
• Implement an effective system for receiving and responding to patient safety alerts, recalls and rapid response reports issued by the Medicines and Healthcare products Regulatory Agency, the Central Alerting System and other relevant bodies, such as Public Health England.