3 July 2019
During an inspection looking at part of the service
We undertook a focused inspection of Eastfield Dental Care on 3 July 2019. 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 who was supported by a specialist dental adviser.
We undertook a comprehensive inspection of Eastfield Dental Care on 2 November 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 and was in breach of regulation 17 and regulation 19 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 Eastfield Dental Care 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. We then inspect again after a reasonable interval, focusing on the areas 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 breaches we found at our inspection on 2 November 2018.
We found this practice was providing well-led care in accordance with the relevant regulations.
Background
Eastfield Dental Centre is in the city of Leicester and provides NHS and private treatment to adults and children.
There is stepped access to the premises and therefore it is not suitable for people who use wheelchairs and those with pushchairs. Free unlimited stay car parking is available on the street directly outside the practice.
The dental team includes three dentists, two dental nurses, one dental hygienist and one receptionist. One of the dental nurses also works as the practice manager. The practice has two treatment rooms; both are on ground floor level.
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 one dentist (practice principal) and one of the dental nurses who also works as the practice manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open: Monday from 9am to 5pm, Wednesday from 8.30am to 5pm, Thursday from 9am to 2.30pm and Friday from 9am to 1pm. Appointments were also available with the hygienist on Saturdays.
Our key findings were:
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Processes had improved in relation to significant event and untoward incident reporting.
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There were systems for monitoring and improving quality, although we noted the infection control audit was overdue and a radiograph audit required completion. We were sent evidence after the day to demonstrate completion.
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The provider had a system to enable them to monitor staff completion of required training. Staff had updated their training in the Mental Capacity Act 2005.
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The provider had or was in the process of updating policy provision and protocol. This included the review of risk assessments.
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Servicing records for equipment were up to date and five-year fixed wiring testing had been undertaken.
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We saw that there was a system for the review of national patient safety alerts.
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The practice had not recruited any new members to the team. The provider provided assurance as to how they would ensure compliance with legislative requirements, should any new staff be appointed to work within the practice.
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The provider had moved to a safer sharps system.
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All required emergency medicines and equipment were held in the kit. We noted some needles and syringes that required disposal as the date for their safe use had expired.
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Staff had discussed Gillick competence to ensure awareness when providing treatment to young people.
There were areas where the provider could make improvements. They should:
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Review the practice’s protocols to ensure of radiography and infection prevention and control are undertaken at regular intervals to improve the quality of the service. The practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.