Mr G Lai & Associates - Willesden

We carried out this announced comprehensive inspection on 22 November 2022 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 practice was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a Care Quality Commission (CQC) inspector who was supported by a specialist dental advisor.

To get to the heart of patients’ experiences of care and treatment, we always ask the following 5 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:

• Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
• Patients were treated with dignity and respect and staff 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.
• Staff felt involved and supported and worked as a team.
• Complaints were dealt with positively and efficiently.
• The dental clinic had information governance arrangements.
• The clinical staff generally provided patients’ care and treatment in line with current guidelines. Improvements were needed to their knowledge and understanding of the National of Institute of Excellence (NICE) guidelines and consent.
• There were some systems in place to support continuous improvement. However, there was ineffective leadership and a lack of oversight for the day-to-day management of the service.
• The dental clinic did not appear visibly clean and well-maintained.
• The practice did not have infection control procedures which reflected published guidance.
• There were ineffective processes in place to prevent abuse of vulnerable adults and children.
• Risks to staff and patients from undertaking of regulated activities had not been suitably identified and mitigated.
• The provider did not have suitable staff recruitment procedures to comply with current legislation.
• Improvements were needed to the systems and processes for seeking and learning from patient feedback.

Background

The provider Mr G Lai & Associates has three practices 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 located close to public transport links, and car parking spaces are available nearby.

The practice is not fully accessible to people who use wheelchairs and those with pushchairs. The practice communicated this to new patients before booking and they signposted people with mobility issues to nearby practices.

The dental team includes the principal dentist, an associate dentist, a foundation dentist, a qualified dental nurse, a trainee dental nurse and a receptionist. The practice has 3 treatment rooms.

At the time of inspection there was no registered manager in post as required as a condition of the provider’s registration with the Commission.

During the inspection we spoke with the principal dentist, the associate dentist, the qualified dental nurse, the trainee dental nurse and the receptionist. 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

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

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulations the provider was not meeting are at the end of this report.

There were areas where the provider could make improvements. They should:

• Take action to ensure the clinicians carry out patient assessments and ensure they are in compliance with current legislation and take into account relevant nationally recognised evidence-based guidance.
• Improve and develop staff awareness of the requirements of the Mental Capacity Act 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.
• Implement processes and systems for seeking and learning from patient feedback with a view to monitoring and improving the quality of the service.