Updated 10 September 2018
We undertook a follow up focused inspection of Dovecot Health Centre on 21 August 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 carried out by a CQC inspector.
We undertook a comprehensive inspection of Dovecot Health Centre on 22 May 2018 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 in accordance with the relevant regulations 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 Dovecot Health Centre on our website www.cqc.org.uk.
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 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 22 May 2018.
Background
Dovecot Health Centre is located in Liverpool and provides NHS treatment to adults and children. A small amount of private dentistry is also offered.
There is level access for people who use wheelchairs and those with pushchairs. Car parking is available in the roads around the practice, with a limited number of spaces immediately outside the building.
The dental team includes two dentists and three dental nurses. The dental nurses also provide reception and administrative support. The practice has two treatment rooms.
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 two dentists and one dental nurse. We looked at revised and updated practice policies and procedures and other records about how the service is managed.
The practice is open Monday to Thursday from 9am to 12.45pm and from 2pm to 5.30pm. Friday opening times are from 9am to 12.45pm and from 2pm to 5pm.
Our key findings were:
The provider had acted to make improvements in all areas of governance, including those we highlighted as being in breach of regulations. We found:
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There were systems in place to monitor staff training requirements, including updates on infection prevention and control, safeguarding of adults and children and relevant notifications to CQC, and training on the prevention and management of risk of sepsis.
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Risk assessments were in place in respect of any mercury spillage and for use of latex products and sharps.
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Water temperature checks were in place to support the safe manual cleaning of dental instruments.
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The issue of prescription pads was monitored and recorded; all prescriptions issued could be tracked back to individual clinicians.
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All required recruitment checks for all staff were in place.
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Governance systems were in place to ensure oversight of surgery cleaning and to ensure effective infection control and clinical audit.
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Practice policies and procedures had been reviewed and updated, including the safeguarding policy, to include the safeguarding of vulnerable adults.
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Safeguarding training which included help and guidance for staff on recognising potential cases of modern day slavery, was in place.
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The data protection policy had also been updated to take account of the new General Data Protection Regulation, effective from May 2018.