Updated 22 August 2018
We undertook a focused inspection of Fawdon Dental Practice on 23 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 undertook a comprehensive inspection of Fawdon Dental Practice on 26 April 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 safe and 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 Fawdon Dental Practice 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 safe and well-led areas where improvement was required.
As part of this inspection we asked:
• Is it safe?
• Is it well-led?
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 breach we found at our inspection on 26 April 2018.
Are services effective?
We found this practice was providing effective care in accordance with the relevant regulations.
The practice had clear arrangements when patients needed to be referred to other dental or health care professionals. An effective referral system was now in place to monitor the progress of all referrals.
Are services responsive?
We found this practice was providing responsive care in accordance with the relevant regulations.
The provider arranged for a competent person to carry out a disability access assessment to assess the needs of all groups of patients and implemented reasonable changes.
Are services well-led?
We found this practice was providing well-led care in accordance with the relevant regulations.
The provider had made improvements to put right the shortfalls and had responded to the regulatory breaches we found at our inspection on 26 April 2018.
Background
Fawdon Dental Practice is in Newcastle Upon Tyne 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 near the practice.
The dental team includes a principal dentist, an associate dentist and two trainee dental nurses (one of whom is also the practice manager). All dental nurses also undertake reception duties. 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 the principal dentist, the practice manager and a trainee dental nurse.
We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday, Tuesday 8.45am to 5.15pm
Wednesday 8.45am to 6pm
Thursday 9.15am to 6.45pm
and Friday 8.45am to 4.30pm
Our key findings were:
- The practice appeared clean and well maintained. We saw repairs had been carried out where required.
- The practice infection prevention and control procedures reflected published guidance except for a few points.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were all available as described in national guidance, with the exception of two sizes of face masks and accessory equipment for the automated external defibrillator (AED).
- The practice had implemented systems to help them manage risk. A legionella risk assessment, fire risk assessment, sharps and general practice risk assessment had been carried out.
- The practice had suitable safeguarding processes for safeguarding vulnerable adults and children. A policy for safeguarding of vulnerable adults and children was available.
- The provider improved their staff recruitment procedures.
- Staff took care to protect people’s privacy and personal information.
- The practice leadership required improvement. A culture of continuous improvement within the practice was present and this required strengthening.
- Staff felt involved and supported and worked well as a team. The practice manager required more support and time to perform their role efficiently.
- An effective referral system was implemented to monitor referrals.
There were areas where the provider could make improvements. They should:
- Review the practice's recruitment procedures to ensure accurate, complete and detailed records are maintained for all staff.
- Review the practice's policy for hazardous substances identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken for hazardous materials held on-site.
- Review the practice’s infection control procedures and protocols taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’.