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College Street Dental Centre

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Reports


Inspection carried out on 14 November 2017

During an inspection to make sure that the improvements required had been made

We carried out a focused inspection of College Street Dental Centre on 14 November 2017.

The inspection was led by a CQC inspector who had access to telephone support from a dental clinical adviser.

We carried out this inspection focusing only on the safe key question to check on information we had received relating to this aspect of care at this practice.

We carried out the inspection to follow up concerns we originally identified during a comprehensive inspection at this practice on 2 September 2015 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions.

At a comprehensive inspection we always ask the following five questions to get to the heart of patients’ experiences of care and treatment:

  • Is it safe?
  • Is it effective?
  • Is it caring?
  • Is it responsive to people’s needs?
  • Is it well-led?

When one or more of the five questions is 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.

At the previous comprehensive inspection we found the registered provider was providing effective, caring, responsive and well led care in accordance with relevant regulations. We judged the practice was not providing safe care in accordance with regulation 12 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 Castle Street Dental Centre on our website www.cqc.org.uk.

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 to put right the shortfalls and deal with the regulatory breach we found at our inspection on 2 September 2015.

Inspection carried out on 2nd September 2015

During a routine inspection

We carried out an announced comprehensive inspection on 2 September 2015 to ask the practice the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this practice was not providing safe care in accordance with the relevant regulations.

Are services effective?

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

Are services caring?

We found that this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

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

Are services well-led?

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

Background

We carried out an announced comprehensive inspection on 2 September 2015 as part of our national programme of comprehensive inspections.

College Street Dental Centre provides private treatment to patients of all ages. The practice provides general dental services and specialist treatment such as implants and orthodontics.

The practice is in a converted residential property close to the centre of Petersfield. The practice has one surgery downstairs, three further surgeries on the first floor, a decontamination area that is also used to take radiographs and a separate waiting area. The practice had a computed tomography (X-ray CT) machine, which is a specialist X–ray machine that makes use of computer-processed combinations of many X-ray images taken from different angles to produce cross-sectional images

The practice team consists of three dentists, a visiting consultant orthodontist, dental therapist, dental hygienist, practice manager, business development manager and three dental nurses.

The practice manager is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons 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 our inspection we spoke with two patients and reviewed five comments cards, which patients had completed in the two weeks prior to our visit. Seven people provided feedback about the service and all commented positively about the high quality care that they received at the practice.

Our key findings were:

  • The practice had risk assessments in place to manage and monitor risks to patients and staff.
  • The practice had effective systems in place to ensure that instruments used on patients were appropriately decontaminated.
  • Patients care and treatment was assessed, planned and delivered according to their individual needs.

We identified regulations that were not being met and the provider must:

  • Review the procedures for the decontamination of equipment to meet the essential requirements of HTM 01-05 and update action plans to outline how the surgery will move towards meeting current best practice requirements. Floors in the decontamination room must be sealed and bins used for the disposals of hazardous waste must have lids that can be closed and operated in a way that does not compromise infection control. A schedule of cleaning and daily cleaning records must be maintained. Policies and procedures must all reflect the name of the current decontamination lead.
  • Ensure that patient records stored in the decontamination area are removed and that other cupboards can be closed.
  • Review the procedures for electrical safety in the decontamination room.
  • Ensure that equipment and materials that have passed it’s expiry date for use are removed.

You can see full details of the regulations not being met at the end of this report.

There were areas where the provider could make improvements and should:

  • Review the policy for safeguarding vulnerable adults and children in line with the recommended date.

  • Review the distribution of NICE guidance to staff and record any action taken as a result of guidance received.
  • A single system for the management of referrals should be consistently operated and procedures put into place to process mail when a clinician is absent.
  • Share the findings of the last private care plan provider audit with management and staff.