Updated 24 August 2018
We undertook a inspection on the 20 February 2018 and then a focused inspection on 31 July 2018. 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 inspect , focusing on the area where improvement was required.
As part of this inspection we asked:
• Is it well-led?
Our findings were:
Are services safe?
We found this practice was providing safe care in accordance with the relevant regulations.
Are services effective?
We found this practice was providing effective care in accordance with the relevant regulations.
Are services caring?
We found this practice was providing caring services in accordance with the relevant regulations.
Are services responsive?
We found this practice was providing responsive care in accordance with the relevant regulations.
Are services well-led?
We found this practice was not providing well-led care in accordance with the relevant regulations.
The provider had not made sufficient improvements to put right all the shortfalls and had not responded to all the regulatory breach(es) we found at our inspection on 20 February 2018.
Background
Townend Dental Practice is in Caterham and provides NHS and private treatment to adults and children.
There is some level access for people who use wheelchairs and those with pushchairs. Car parking spaces, are available near the practice.
The dental team includes 1 dentist, 1 dental nurse, 1 dental hygienist and 1 receptionist. The practice has 1 treatment room.
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 1 dentist, 1 dental nurse and one receptionist. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open: Monday to Friday 09.00- 17.30
Our key findings were:
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.
Full details of the regulation/s the provider was/is not meeting are at the end of this report.
There were areas where the provider could make improvements. They should:
- Review the way staff are supported to make sure that staff are able to meet the requirements of the relevant professional regulator throughout their employment, such as requirements for continuing professional development.
- Review the practice’s arrangements for ensuring good governance and leadership are sustained in the longer term.
- The provider has partly reviewed the practice's protocols for completion of dental care records. This now needs to take into account guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.
- Review the analysis of the grades for the quality of radiographs to ensure these are correctly recorded over each audit cycle and for each dentist.
- Review the protocols and procedures to ensure staff are up to date with their mandatory training and their Continuing Professional Development (CPD)
- Review the practice’s policies to ensure all documents are providing the latest requirements and guidance.
- Review the practice’s policies to ensure all documents are providing the latest requirements and guidance.
- Review the practice's current performance review systems and have an effective process established for the on-going assessment and supervision of all staff.