Updated 2 April 2019
We undertook a focused inspection of the Compass Clinic on 18 March 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 dental specialist advisor.
We undertook a comprehensive inspection of the practice on 24 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 Compass Clinic on our website www.cqc.org.uk.
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.
As part of this inspection we asked:
• Is it well-led?
Background
The Compass Clinic provides both NHS and private treatment to patients of all ages. The practice opens on Monday to Friday, from 9am to 5pm. The practice is one of two owned by the company, and has a sister practice a few miles away. The practice is based in the local community hospital and shares many of its facilities.
There is level access for people who use wheelchairs and those with pushchairs.
The permanent dental team includes one dentist, one dental nurse a practice manager and reception staff. A hygienist works two afternoons a month. The practice has two treatment rooms.
As a condition of registration, the practice must have a person registered with the Care Quality Commission 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 is the company’s chief executive officer, who also acts as the practice manager.
During the inspection we spoke with one dentist, one dental nurse and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.
Our findings were:
Are services Well-led?
We found this practice was providing well-led care in accordance with the relevant regulations.
Key findings
The provider had made satisfactory improvements to put right many of the shortfalls we found at our inspection on 24 May 2018. However, there remained areas where the provider could make improvements. They should:
- Review the practice's recruitment procedures to ensure that appropriate DBS checks are completed prior to new staff commencing employment at the practice.
- Review the availability of an interpreter service for patients who do not speak English as their first language.
- Review the practice's staffing levels and ensure the practice can provide routine appointments in a timely manner to its patients.