Archived: Broadway Dental Surgery

We undertook a focused inspection of Broadway Dental Surgery on 9 January 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 led by a CQC inspector.

We undertook a comprehensive inspection of Broadway Dental Surgery on 20 May 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 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 Broadway Dental Surgery on our website www.cqc.org.uk.

As part of this inspection 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 (requirement notice only). We then inspect again after a reasonable interval, focusing on the area(s) 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 breach we found at our inspection on 20 May 2019.

We found this practice was providing well-led care in accordance with the relevant regulations.

Background

The practice is in Woodhall Spa, a village in Lincolnshire and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available in the practice’s car park. There is also on road public car parking directly outside the practice.

The dental team includes five dentists, four dental nurses, two trainee dental nurses, one dental hygienist, one dental hygiene therapist, two receptionists and a practice manager. The practice manager is also qualified as a dental nurse.

The practice has five treatment rooms, all on ground floor level.

Services include general dentistry and orthodontic treatments. The practice is also a training practice for dentists new to practice. One of the associate dentists is a trainer.

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 the principal dentist and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open: Monday to Saturday from 9am to 1pm and 2pm to 5pm.

Our key findings were:

• A more effective framework for incident reporting was in operation. We noted where learning points had been identified for staff and saw that preventative action was taken when necessary.

• Management oversight of staff training completion had improved.
• The induction process was documented when new staff joined the practice and we saw evidence to support this.
• Most actions had been taken to address recommendations in the legionella risk assessment. We found an area for further action. This was addressed after our visit.
• Hygienists were supported by a dental nurse. A risk assessment had been completed for the occasions when they worked alone.
• The risks presented by fire had been mitigated.
• X-ray equipment had been subject to routine testing.
• Patient safety alerts had been subject to review and documentation was held to support this.
• New staff had recently been recruited and we noted there was some information missing in their personnel files, such as references which had been sought but not yet received. The practice manager acted to follow this up after our visit.
• Monitoring for NHS prescriptions required further review to ensure that it could be identified if an individual prescription was taken inappropriately.
• Clear face masks were obtained for the emergency equipment kit.

There were areas where the provider could make improvements. They should:

• Improve the security of NHS prescription pads in the practice and ensure there are systems in place to track and monitor their use.
• Implement an effective recruitment procedure to ensure that appropriate checks are completed prior to new staff commencing employment at the practice.

We carried out this announced inspection on 20 May 2019 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a CQC inspector who was supported by a specialist dental adviser.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

These questions form the framework for the areas we look at during the inspection.

Our findings were:

Are services safe?

We found that this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this practice was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this practice was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this practice was not providing well-led care in accordance with the relevant regulations.

Background

The practice is in Woodhall Spa, a village in Lincolnshire and provides NHS and private treatment to adults and children.

The current provider has taken over the sole ownership of the practice from March 2019. Prior to this, they were in a partnership with the previous owner from October 2018.

There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available in the practice’s car park. There is also on road public car parking directly outside the practice.

The dental team includes six dentists, four dental nurses, (a previously registered nurse is also undertaking work at the practice and is waiting for their registration to be confirmed), three trainee dental nurses, (one of the dental nurses also works as a receptionist), two dental hygienists and a receptionist. A practice manager is also employed.

The practice has five treatment rooms, all on ground floor level.

Services include general dentistry and the practice has a contract with NHS England for the provision of orthodontic treatments. The practice is also a training practice for dentists new to practice. One of the associate dentists is a trainer.

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.

On the day of inspection, we collected 27 CQC comment cards filled in by patients.

During the inspection we spoke with two dentists, three dental nurses, one dental hygienist, a receptionist and the practice manager. We looked at practice policies, patient feedback and procedures and other records about how the service is managed.

The practice is open: Monday to Saturday from 9am to 1pm and 2pm to 5pm.

Our key findings were:

• The practice appeared clean and well maintained.
• The provider had infection control procedures which reflected published guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available, with exception of four sizes of clear face masks that were missing.
• The practice did not have all suitable systems to help them manage risk to patients and staff. For example, the risks presented by fire, legionella and lone working required review.
• The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children. We did not view evidence to show that all staff had completed training in safeguarding however.
• The provider had a staff recruitment policy and procedure, but this was not always complied with in relation to the recruitment of new staff.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• Staff were providing preventive care and supporting patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• Staff felt involved and supported and worked well as a team.
• The provider welcomed feedback from staff and patients about the services they provided.
• The provider dealt with one complaint received positively and efficiently. It was not evident that learning was shared amongst the team however.
• The provider had suitable information governance arrangements.
• Governance arrangements required strengthening. Not all risks arising from the undertaking of the regulated activities had been suitably identified and mitigated.

We identified regulations the provider was not complying with. They must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulation the provider was not meeting are at the end of this report.

There were areas where the provider could make improvements. They should:

• Review the availability of equipment in the practice to manage medical emergencies taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.
• Review the security of NHS prescription pads in the practice and ensure there are systems in place to track and monitor their use.