Archived: Poynton House Dental Surgery

We undertook a follow up focused inspection of Poynton House Dental Surgery on 16 September 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 specialist dental adviser.

We undertook a comprehensive inspection of Poynton House Dental Surgery on 21 February 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 and 19 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 Poynton House Dental Surgery on our website www.cqc.org.uk.

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 area(s) 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 breaches we found at our inspection on 21 February 2019.

Background

Poynton House Dental Surgery is in Market Drayton and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available outside the practice in their dedicated car park.

The dental team includes three dentists, four dental nurses, two dental hygienists and one receptionist. The provider had also recruited an independent practice advisor who visited the practice on a monthly basis to assist with its compliance and management. 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.

During the inspection we spoke with the principal dentist and one dental nurse who had taken on some managerial duties at the practice. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open between 9am and 5pm from Monday to Thursday. It is open between 9am and 4pm on a Friday.

Our key findings were:

• Improvements had been made in the practice’s staff training, audit processes and actions had been taken that had previously been identified on risk assessments.
• Improvements had been made in record keeping and this was now in line with current guidance.

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

• Implement an effective system for recording, investigating and reviewing incidents with a view to preventing further occurrences and ensuring that improvements are made as a result.

We undertook a follow up inspection of Poynton House Dental Surgery on 21 February 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 second CQC inspector.

We undertook a comprehensive inspection of Poynton House Dental Surgery on 16 July 2018 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 12, 17 and 19 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 Poynton House Dental Surgery on our website www.cqc.org.uk.

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 not providing well-led care in accordance with the relevant regulations.

The provider had made insufficient improvements to put right the shortfalls and had not responded to all three of the regulatory breaches we found at our inspection on 16 July 2018.

Background

Poynton House Dental Surgery is in Market Drayton and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available outside the practice in their dedicated car park.

The dental team includes four dentists, five dental nurses, two dental hygienists and one receptionist. The existing practice manager was due to go on maternity leave shortly and one of the dental nurses would be given this role in their absence. 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.

During the inspection we spoke with one dental nurse and the practice manager (who was also a qualified dental nurse). The principal dentist was due to be present but extenuating circumstances led to their absence on the day of our visit. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open between 9am and 5pm from Monday to Thursday. It is open between 9am and 4pm on a Friday.

Our key findings were:

• A written induction programme had been introduced and implemented since our previous visit.
• The practice had made improvements in their processes relating to safety alerts, staff immunisation records, induction programmes and fire safety.
• Dental care record keeping had improved.
• Radiography audits were not undertaken at regular intervals to help improve the quality of service.
• Infection control and record keeping audits did not have documented learning points and the practice was unable to demonstrate the resulting improvements.
• There was no system in place to ensure that untoward events were appropriately documented, investigated and analysed to prevent their reoccurrence.
• The practice did not have any formal policies, processes or systems to identify, manage, follow up and where required refer patients for specialist care when presenting with bacterial infections.
• Actions from the fire and the Legionella risk assessment had not been carried out.
• Record keeping was not consistently in line with current guidance.
• Staff training, learning and development needs were not reviewed at appropriate intervals and there was no effective process for the ongoing assessment and supervision of all staff employed.
• Recruitment procedures were not consistently documented. This included obtaining and suitably documenting staff’s photographic identity and evidence of indemnity insurance.

We identified regulations the provider was not meeting. They must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure specified information is available regarding each person employed.

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