Leven Vale Dental Practice Also known as Leven Vale DP Ltd

We undertook a desk-based follow-up inspection of 8 June 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 undertaken by a CQC inspector as desk-based review.

We undertook a comprehensive inspection Leven Vale Dental Practice on 12 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 well led care and was in breach of regulations 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 Leven Vale Dental Practiceon our website .

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 breach we found at our inspection on 12 November 2019.

Background

Leven Vale Dental Practice is in Yarm and provides NHS and private dental treatment to adults and children.

The practice is in a purpose-built ground floor premises. There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice.

The dental team includes a principal dentist, an associate dentist, three foundation dentists, a visiting dentist with a special interest in endodontics, a dental hygiene therapist, seven dental nurses, a practice manager and receptionist.

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.

The practice is open: Monday to Thursday 9am to 5pm and Friday 9am to 4pm.

Our key findings were :

• Systems for management of manual cleaning of instruments had improved..
• Improvements had been made to the access to medical emergency drugs and equipment.
• Systems were in place for the checking of staff’ immunity to Hepatitis B.
• Staff safeguarding training is in place and complete.
• Systems had been implemented to improve overall management and governance systems at the practice.

We carried out this announced inspection on 12 November 2019 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a CQC inspector who was supported by a specialist dental adviser.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

•Is it safe?

•Is it effective?

•Is it caring?

•Is it responsive to people’s needs?

•Is it well-led?

These questions form the framework for the areas we look at during the inspection.

Our findings were:

Are services safe?

We found that this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this practice was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this practice was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this practice was not providing well-led care in accordance with the relevant regulations.

Background

Leven Vale Dental Practice is in Yarm and provides NHS and private dental treatment to adults and children.

The practice is in a purpose-built ground floor premises. There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice.

The dental team includes a principal dentist, four associate dentists, a visiting dentist, seven dental nurses, a dental hygiene therapist and a receptionist. A practice manager has recently been appointed to support the dental team. The practice has four 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.

On the day of inspection, we collected 38 CQC comment cards filled in by patients. These provided a positive view of the dental team and care provided by the practice.
During the inspection we spoke with three dentists, three dental nurses, the receptionist 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 Thursday 9am to 5pm
Friday 9am to 4pm.

Our key findings were :

• The practice appeared clean and well maintained.
• The provider had infection control procedures which reflected published guidance; improvements could be made to the practice’s manual scrubbing procedures for dental instruments.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available apart from a child sized resuscitation bag. This was ordered on the inspection day. Medical emergency drugs and equipment were not easily accessible to staff.
• The provider had systems to help them manage risk to patients and staff. Risk management systems could be improved in recording of prescriptions and checking of staff’ immunity to Hepatitis B.
• The provider did not have suitable protocols in place for the safeguarding of vulnerable adults and children. Staff had not received training to the appropriate level and were not confident of their responsibilities for safeguarding vulnerable adults and children.
• The provider had thorough staff recruitment procedures.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• Staff provided preventive care and supported patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• The provider should review the leadership, governance and management of the dental practice to promote a culture of continuous improvement.
• Staff felt involved and supported and worked well as a team.
• The provider asked staff and patients for feedback about the services they provided.
• The provider dealt with complaints positively and efficiently.
• The provider had suitable information governance arrangements.
• The practice has been a training practice for newly qualified dentists since 2014.

We identified regulations the provider was not complying with. They must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulation the provider was not meeting is at the end of this report.