Updated 21 December 2020
We undertook a follow up desk-based review of Burnawn House Dental Surgery on 10 December 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.
We undertook a comprehensive inspection of Burnawn House Dental Surgery on 16 March 2020 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 safe and well led care and was in breach of regulations 12, 13, 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 Burnawn House Dental Surgery on our website www.cqc.org.uk.
As part of this review we asked:
• Is it safe?
• 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 (requirement notice only). We then inspect again after a reasonable interval, focusing on the areas where improvement was required.
Our findings were:
Are services safe?
We found this practice was providing safe care in accordance with the relevant regulations.
The provider had made improvements in relation to the regulatory breaches we found at our inspection on 16 March 2020.
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 16 March 2020.
Background
Burnawn House Dental Surgery is in Raunds, a small market town in rural Northamptonshire. It provides mostly NHS dental care and treatment for adults and children.
There is one step access to the practice with use of a portable ramp for people who use wheelchairs and those with pushchairs.
Free car parking spaces are available in a public car park and on street within close distance of the practice.
The dental team includes two dentists (one of these dentists provides ad hoc cover when required) one dental nurse and one receptionist.
The principal dentist has responsibility for practice management. The practice has two treatment rooms, both on ground floor level.
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 review we spoke with the principal dentist. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open: Monday to Friday from 9am to 5.30pm. It closes during lunchtimes between 12.30pm to 2pm.
Our key findings were:
- The practice had obtained the necessary medicines and equipment to allow them to respond to a medical emergency.
- Five-year electrical fixed wiring testing had been completed since our previous inspection visit.
- A fire risk assessment had been completed by an external contractor and the practice had implemented a sharps risk assessment.
- Policies relevant to the practice operations had been implemented, for example, in relation to staff recruitment, infection prevention and control and the management of significant events.
- The practice had recorded two significant events since our previous visit. There was evidence that these had been investigated and actions taken in response.
- Cleaning schedules had been introduced for staff to complete when undertaking these duties.
- Staff now had an individual training record held which the provider informed us was monitored.
- Staff had received information about the management of suspected sepsis in patients.
- Staff appraisals had been completed.
- The systems for audit were improving. This included antibiotic prescribing, and infection prevention and control. A formal radiography audit for the associate dentist had not yet been completed, however they were new to working in the practice. Dental record keeping had been reviewed for consistency purposes amongst clinicians and a template was in use by dentists.
- We were informed that monitoring processes were now in place which would identify if an individual prescription was taken inappropriately.
- The provider informed us that rubber dam was being used by clinicians.
- Recruitment processes had been strengthened to ensure suitable staff were employed.
- Changes had not been made to patient access arrangements. The provider told us they were going to consider installing a handrail and call bell in the patient toilet.
There were areas where the provider could make improvements. They should:
- Continue to improve the practice’s arrangements for ensuring good governance and leadership are sustained in the longer term.