Updated 18 July 2023
We undertook a follow up focused inspection of Mr G Lai & Associates - Willesden on 13 June 2023. 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 had previously undertaken a comprehensive inspection of Mr G Lai & Associates - Willesden on 22 November 2022 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 regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
We undertook an unannounced focused follow up inspection on 5 May 2023 and found that the registered provider was in breach of regulation 12, 17 and 18 and was not providing safe and well-led care. Due to the nature of concerns identified during the follow up inspection on 5 May 2023, we served a Notice of Proposal to the provider, proposing to vary a condition on their registration which specifies the locations they are authorised to carry on the regulated activities from, so they would no longer be authorised to carry on the regulated activities from the location Mr G Lai & Associates – Willesden.
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 safe?
• Is it well-led?
During the inspection on 13 June 2023, we found that the risks identified on 5 May 2023 had been sufficiently mitigated. Subsequently, we have withdrawn our notice of proposal to vary a condition on the provider`s registration which specifies the locations they are authorised to carry on the regulated activities from.
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 5 May 2023.
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 5 May 2023.
Background
The provider has 3 locations and this report is about Mr G Lai & Associates – Willesden.
Mr G Lai & Associates - Willesden is in the London Borough of Brent and provides NHS and private dental care and treatment for adults and children.
The practice is not fully accessible to people who use wheelchairs and those with pushchairs. The practice communicates this to new patients before booking, and signpost people with mobility issues to nearby practices. Car parking spaces are available near the practice.
The dental team includes the principal dentist, an associate dentist, a foundation dentist, a qualified dental nurse and a trainee dental nurse. The practice has 3 treatment rooms.
During the inspection we spoke with the principal dentist, the associate dentist and 2 dental nurses. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday to Friday 9.30am to 6pm.
There were areas where the provider could make improvements. They should:
- Take action to ensure that all clinical staff have adequate immunity for vaccine preventable infectious diseases.
- Take action to ensure the regulated activities at Mr G Lai & Associates - Willesden are managed by an individual who is registered as a manager.