Updated 8 January 2019
We undertook a focused inspection of Fence Houses Dental Practice on 13 December 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 who was supported remotely by a specialist dental adviser.
We undertook a comprehensive inspection of Fence Houses Dental Practice on 4 September 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 regulations 9, 12, 17 and 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 Fence Houses Dental Practice on our website www.cqc.org.uk.
As part of this inspection we asked:
• Is it safe?
• Is it effective?
• 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 improvements were required.
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 in relation to the regulatory breaches we found at our inspection on 4 September 2018.
Are services effective?
We found this practice was providing effective care in accordance with the relevant regulations.
The provider had made improvements in relation to the regulatory breaches we found at our inspection on 4 September 2018.
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 4 September 2018.
Background
Fence Houses Dental Practice is in Houghton Le Spring and provides NHS and private treatment to adults and children.
There is a small step at the entrance to the practice. Staff are available to help people who use wheelchairs and those with pushchairs if assistance is needed into the practice. Car parking spaces are available near the practice.
The dental team includes three dentists (including the principal dentist), four dental nurses and a receptionist. One of the dental nurses is also the practice manager. The practice has two treatment rooms.
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 two dentists 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-Friday 9am to 5pm
Saturday 9am to 1pm.
Our key findings were:
- The provider had infection control procedures which reflected published guidance.
- The practice had effective leadership.
- The provider had improved their staff recruitment procedures.
- Training of staff was monitored efficiently.
- Policies were re-written and updated where applicable.
- Risk assessments had been reviewed and recommended actions were implemented.
- Referrals and prescriptions were monitored efficiently.
- Dental records were audited by the principal dentist to ensure treatment was reflective of national guidance.
- The practice had closed-circuit television (CCTV) on the premises; a policy had been created. There was no privacy impact statement in place.
There were areas where the provider could make improvements. They should:
- Review the practice's protocols for patient assessments and ensure they are in compliance with current legislation and take into account relevant nationally recognised evidence-based guidance. In particular, for undertaking X-rays and monitoring of gum health e.g. using the basic periodontal examination (BPE) index.