Updated 20 March 2020
We undertook a follow up focused inspection of Bramley Dental Practice Annexe - Cross Street on the 10 February 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 who was supported by a specialist dental adviser.
We undertook a comprehensive inspection of Bramley Dental Practice Annexe - Cross Street on 4 November 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 safe and well led care and was in breach of regulation 12 and 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 Bramley Dental Practice Annexe - Cross Street on our website www.cqc.org.uk.
As part of this inspection we asked: Remove as appropriate:
• Is it safe?
• 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 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 breach we found at our inspection on 4 November 2019.
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 November 2019.
Background
Bramley Dental Practice Annexe - Cross Street is located in Bramley, Rotherham and provides NHS and private treatments to adults and children. The practice is a foundation dentist training practice. The annexe is a separate location from the main practice 25 yds. away on the main street of Bramley. Access to the practice is via one flight of stairs and car parking is available nearby.
Access for wheelchair users and pushchairs is via a portable ramp into the main practice reception area. Car parking spaces are available near the practice.
The dental team includes a principal dentist, a foundation training dentist and seven associate dentists, 14 dental nurses (five of whom are trainees), one dental hygienist, two dental hygiene therapist and two receptionists and two practice managers. The practice has five treatment rooms.
The practice is owned by a partnership as a condition of registration must have a person registered with the CQC 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 Bramley Dental Practice Annexe - Cross Street is the principal dentist.
During the inspection we spoke with principal dentist and the practice managers. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open: Monday and Tuesday 9am - 6pm, Wednesday to Thursday 9am - 5pm. Friday 9am - 1pm
Our key findings were:
- Legionella management systems reflected current guidance and risk assessment.
- Safer sharps systems reflected current regulations.
- Risk mitigation was in place for staff without Hepatitis B vaccination results.
- An effective system was in place to respond to patient safety alerts.
- Clinical waste management complied with published guidance.
- Recommendations made by the Radiation Protection Advisor had been acted upon.
- Systems to ensure staff employed continued to meet the professional standards was effective.
- Recruitment processes reflected current legislation.
- The process to audit implant placement was in progress.