Updated 15 February 2023
We undertook a follow up focused inspection of Alma Terrace on 25 January 2023. This inspection was carried out to review 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 had remote access to a specialist dental advisor.
We had previously undertaken a comprehensive inspection of Alma Terrace on 20 September 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 well-led care and was in breach of regulation 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 Alma Terrace dental practice on our website www.cqc.org.uk.
When 1 or more of the 5 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 where improvement was required.
As part of this inspection we asked:
- Is it well-led?
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 20 September 2022.
Background
The provider has 3 practices and this report is about Alma Terrace.
The practice is in Silloth in Cumbria and provides NHS and private dental care and treatment for adults and children.
The practice is located in a mid-terrace converted house. The surgery is located on the first floor and accessible only by stairs. Car parking spaces are available outside the practice.
The dental team includes 1 dentist, 1 dental nurse, 1 receptionist and 1 practice manager/dental nurse. The practice has 1 treatment room.
During the inspection 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, Tuesday and Thursday from 9am to 1pm and from 2pm to 7pm
Wednesday from 9am to 1pm
Friday 9am to 2pm.
There were areas where the provider could make improvements. They should:
- Take action to ensure the practice's fire safety risk assessment considers all risks and ensure ongoing fire safety management is effective.
- Review the practice’s infection control procedures and protocols taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’. In particular relating to the fixtures and fittings in the decontamination room.