24 August 2020
During an inspection looking at part of the service
We undertook a follow up desk-based review of Birchfields Family Dental Care on 24 August 2020. This review 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 review was led by a CQC inspector who had remote access to a specialist dental adviser.
We undertook a comprehensive inspection of Birchfields Family Dental Care on 10 December 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 12 and 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 Birchfields Family Dental Care on our website www.cqc.org.uk.
As part of this review 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 or review again after a reasonable interval, focusing on the area 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 10 December 2019.
Background
Birchfields Family Dental Care is in Longsight, Manchester and provides NHS and private dental care and treatment for adults and children. The practice also provides fixed orthodontics on a private basis.
There is level access to the practice for people who use wheelchairs and those with pushchairs. On street parking was available near the practice.
The dental team includes three dentists, three dental nurses who also have reception and administrative duties (of which two are trainees) and a practice manager. The practice has two 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 desk-based review we spoke with the practice manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday 08:00 - 17:00
Tuesday 08:00 - 18:30
Wednesday 08:00 - 13:00
Thursday 08:00 - 18:30
Friday 08:00 - 13:00
Our key findings were:
- The provider had implemented effective governance systems to monitor their service against the regulations and ensure their systems were effective.
- The provider reviewed processes to identify and manage risk to patients and staff.
- Sharps and immunity risks were reviewed and evidence of immunity to hepatitis B was obtained for clinical staff.
- Quality assurance and audit processes were introduced to assess whether care was delivered in line with national standards and guidance.
- Staff completed training in sepsis and Mental Capacity Act awareness to improve their understanding of these areas and their responsibilities.
- Incident reporting and investigation systems were improved and we saw evidence of incidents that had been reported and investigated appropriately.