Updated 12 March 2020
We undertook a focused inspection of Broadway Dental Surgery on 9 January 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 Broadway Dental Surgery on 20 May 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 Broadway 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 20 May 2019.
We found this practice was providing well-led care in accordance with the relevant regulations.
Background
The practice is in Woodhall Spa, a village in Lincolnshire and provides NHS and private treatment to adults and children.
There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available in the practice’s car park. There is also on road public car parking directly outside the practice.
The dental team includes five dentists, four dental nurses, two trainee dental nurses, one dental hygienist, one dental hygiene therapist, two receptionists and a practice manager. The practice manager is also qualified as a dental nurse.
The practice has five treatment rooms, all on ground floor level.
Services include general dentistry and orthodontic treatments. The practice is also a training practice for dentists new to practice. One of the associate dentists is a trainer.
The practice is owned by an individual who is the principal dentist there. 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 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 Saturday from 9am to 1pm and 2pm to 5pm.
Our key findings were:
- A more effective framework for incident reporting was in operation. We noted where learning points had been identified for staff and saw that preventative action was taken when necessary.
- Management oversight of staff training completion had improved.
- The induction process was documented when new staff joined the practice and we saw evidence to support this.
- Most actions had been taken to address recommendations in the legionella risk assessment. We found an area for further action. This was addressed after our visit.
- Hygienists were supported by a dental nurse. A risk assessment had been completed for the occasions when they worked alone.
- The risks presented by fire had been mitigated.
- X-ray equipment had been subject to routine testing.
- Patient safety alerts had been subject to review and documentation was held to support this.
- New staff had recently been recruited and we noted there was some information missing in their personnel files, such as references which had been sought but not yet received. The practice manager acted to follow this up after our visit.
- Monitoring for NHS prescriptions required further review to ensure that it could be identified if an individual prescription was taken inappropriately.
- Clear face masks were obtained for the emergency equipment kit.
There were areas where the provider could make improvements. They should:
- Improve the security of NHS prescription pads in the practice and ensure there are systems in place to track and monitor their use.
- Implement an effective recruitment procedure to ensure that appropriate checks are completed prior to new staff commencing employment at the practice.