Updated 8 December 2020
We undertook a follow up desk-based review of Hartcliffe Dental Practice Partnership on 4 November 2020. 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 carried out by a CQC inspector.
We undertook a comprehensive inspection of Hartcliffe Dental Practice Partnership on 24 July 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 Good governance and 19 Fit and proper persons employed 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 Hartcliffe Dental Practice Partnership 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 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 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 comprehensive inspection of 24 July 2019.
Background
Hartcliffe Dental Practice Partnership is in Hartcliffe, Bristol and provides NHS and private treatment for adults and children.
There is level access for people who use wheelchairs and those with pushchairs. On-street car parking spaces are available near the practice.
The dental team includes three dentists, one foundation dentist, one qualified dental nurse, two trainee dental nurses, one dental hygienist, a practice manager, and one receptionist. The practice has three treatment rooms.
The practice is owned by a partnership and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run. The registered manager at Hartcliffe Dental Practice Partnership is the senior partner.
During our review, we spoke with the provider (also a dentist) and the practice manager. We looked at practice policies and procedures and other records in relation to the breaches of regulation.
The practice is open:
8:30am to 5pm Monday to Friday
Our key findings were:
- There was an effective system in place to monitor staff training to ensure staff were up to date.
- New staff employed had an appropriate induction.
- Action had been taken to ensure fire safety had been risk assessed in accordance with current Legislation and subsequent actions had been identified and completed.
- Systems to ensure substances hazardous to health had been risk assessed were still in progress.
- There were effective systems in place to monitor infection control processes.
- There were effective systems to manage incidents and these were recorded using reporting tools.
- There were systems in place to review patient dental care records at regular intervals.
- There was an effective system in place to ensure policies and procedures were kept up to date with current guidelines.
- Specified information was available for each person employed, according to legislation and where this had not been possible there was a risk assessment in place
- Clinical staff had been risk assessed where staff they were either non-responders or not fully immunised for Hepatitis B.
- An audit had been carried out for prescribing antibiotics taking into account the guidance provided by the Faculty of General Dental Practice.
- There were procedures in place in relation to the Accessible Information Standard to ensure that the requirements were complied with.
There were areas where the provider could make improvements. They should:
- Review the system to ensure patient referrals to other dental or health care professionals are centrally monitored to ensure they are received in a timely manner and not lost.
- Improve audits, in particular, clinical records, to ensure they have clearly documented learning points and the resulting improvements can be demonstrated.