Updated 20 March 2019
We undertook a follow up focused inspection of The Welbeck Clinic on 19 February 2019. 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 The Welbeck Clinic on 3 October 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 or well led care and was in breach of regulation 17 – Good governance 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 The Welbeck Clinic on our website www.cqc.org.uk.
• 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. We then inspect again after a reasonable interval, focusing on the areas 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 3 October 2018.
Background
The Welbeck Clinic is in the London Borough of Westminster. The practice provides private dental treatment to adults.
The practice is situated close to public transport bus and train services.
The dental team includes the principal dentist, five associate dentists, one dental hygienist and two dental nurses. The clinical team are supported by a practice manager and one receptionist.
The practice is owned by a company and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run. The registered manager at The Welbeck Clinic was the principal dentist.
During the inspection we spoke with the principal dentist, one dental nurse, 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 Friday between 9am and 6pm.
Our key findings were:
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Improvements had been made so that infection prevention and control audits were carried out in line with current guidance.
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There were arrangements to monitor and improve quality in relation to dental radiography though a system of audits.
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Improvements had been made to the practice systems so that risks were assessed in relation to the premises and fire. The findings from these assessments were reviewed and acted on to mitigate risks.
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Improvements had been made to the information governance arrangements to ensure that these were in compliance with General Data Protection Regulations requirements (GDPR) (EU) 2016/679.
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The practice’s sharps procedures were in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
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There were suitable systems for the storage of products identified under Control of Substances Hazardous to Health (COSHH) 2002 Regulations and a risk assessment was in place to assess and help mitigate these risks.
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Improvements had been made to the practice protocols for recording in the patients’ dental care records or elsewhere the reason for taking the X-ray and quality of the X-ray ensuring compliance with the Ionising Radiation (Medical Exposure) Regulations (IRMER) 2000.
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The practice had protocols for the use of closed circuit television cameras (CCTV) taking into account guidelines published by the Information Commissioner's Office (ICO).
There were areas where the provider could make improvements. They should:
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Review the protocols and procedures to ensure that dental staff who work infrequently at the practice are up to date with their mandatory training and their Continuing Professional Development (CPD).
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Review the practice's protocols for completion of dental care records taking into account guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.