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Inspection Summary


Overall summary & rating

Updated 21 November 2018

We undertook a follow-up focused inspection of Roch Valley Dental on 19 October 2018. 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 Roch Valley Dental on 15 May 2018 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 in accordance with the relevant regulations 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 Roch Valley Dental on our website www.cqc.org.uk.

When one or more of the five questions are not met we require the service to make improvements and send us an action plan. We then inspect again after a reasonable interval, focusing on the area where improvement was required.

As part of this inspection we asked:

• Is it well-led?

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 15 May 2018.

Background

Roch Valley Dental is in Rochdale and provides NHS and private treatment for adults and children.

There is a ramp at the side of the premises for people who use wheelchairs and those with pushchairs. The practice has a free car park, which includes spaces for blue badge holders.

The dental team includes seven dentists (two of whom are foundation dentists), 20 dental nurses (four of whom are trainees), three dental hygiene therapists, three receptionists and a practice manager. The practice has seven treatment rooms. Roch Valley Dental is a foundation training practice. Dental foundation training is a post-qualification training period, mainly in general dental practice, which UK dental graduates need to undertake to work in NHS practice.

The practice is owned by a partnership and as a condition of registration must have a person registered with the Care Quality Commission 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 Roch Valley Dental was the practice manager.

During the inspection we spoke with 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 8:30am to 5:45pm

Our key findings were:

  • The practice had systems to identify and manage risk effectively.
  • The practice had improved safeguarding processes.
  • Staff files had been reviewed and now contained evidence of photographic identification, indemnity and immunity.
  • The safety and use of radiography had been reviewed.
  • A system was in place to audit radiography and infection prevention and control.
  • The practice had introduced a sedation policy, this was in line with nationally agreed guidance.

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

  • Review the process to track and monitor the use of NHS prescription pads.
Inspection areas

Safe

No action required

Updated 21 November 2018

Effective

No action required

Updated 21 November 2018

Caring

No action required

Updated 21 November 2018

Responsive

No action required

Updated 21 November 2018

Well-led

No action required

Updated 21 November 2018

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

The provider had made improvements to the management of the service. This included establishing clear roles and responsibilities for the practice team. The improvements provided a sound footing for the ongoing development of effective governance arrangements at the practice.

We saw how the practice manager had prioritised the areas of concern to ensure that the appropriate action was taken to address them. They introduced systems to prevent the re-occurrence of the concerns. Staff meetings showed that the whole practice team had been involved in the improvement plans and all staff had worked together to implement these.

The practice had systems to identify and manage risk effectively. Risk assessments and action plans were in place and we saw evidence of improvement. For example, in the areas of radiography, staff immunity, sedation, waste segregation, lone workers, Legionella, hazardous substances and the validation of decontamination equipment.

A system was in place to audit radiography and infection prevention and control. Action plans were in place and a re-audit of radiography showed a demonstrable improvement.

The practice had systems to receive patient safety alerts and report adverse reactions. Prescription pads were stored securely. We noted the system to document all prescriptions would not identify if a prescription was missing. The practice manager assured us this would be addressed.

The practice had improved safeguarding processes. A safeguarding information board had been provided and all staff had completed safeguarding training to the appropriate level.

Staff files had been reviewed and now contained evidence of photographic identification, indemnity and immunity.