The Care Quality Commission
  • Dentist
  • Dentist

The Dental Surgery

28 Delaunays Road, Crumpsall, Manchester, Lancashire, M8 4QS (0161) 740 2956

Provided and run by:
Mr. Edward Fisher

All Inspections

2 March 2020

During an inspection looking at part of the service

We undertook a follow up focused inspection of The Dental Surgery on 2 March 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 who was supported by a specialist dental adviser.

We undertook a comprehensive inspection of The Dental Surgery on 24 and 29 October 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 safe or well led care and was in breach of regulations 12 (Safe care and treatment) and 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 Dental Surgery on our website www.cqc.org.uk.

As part of this inspection we asked:

• Is it safe?

• 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 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 24 and 29 October 2019.

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 24 and 29 October 2019.

Background

The Dental Surgery is in Crumpsall, Manchester and provides NHS and private treatment to adults and children.

The practice is not accessible for people who use wheelchairs. On street parking is available near the practice.

The dental team includes three dentists, four dental nurses, a receptionist and a practice manager. The practice has three 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, 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 Thursday 9am to 5pm

Friday 9am to 1pm

Our key findings were:

  • Improvements had been made to the process for managing the risks associated with the carrying out of the regulated activities. These included the risks associated with fire, incident reporting and the structural integrity of the premises. Further improvements were required to help reduce the risks associated with Legionella.
  • A system had been put in place to monitor staff training. We saw evidence staff had completed appropriate ‘highly recommended’ training.
  • The contents of the medical emergency kit reflected nationally recognised guidance.
  • Some improvements had been made to the process for ensuring agency staff were competent for their role.

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

  • Improve the practice’s arrangements for ensuring good governance and leadership are sustained in the longer term.
  • Implement audits for prescribing of antibiotic medicines taking into account the guidance provided by the Faculty of General Dental Practice.
  • Improve the practice protocols regarding auditing patient dental care records to check that necessary information is recorded.

24 October 2019

During a routine inspection

We carried out this announced inspection on 24 October 2019 and a further announced inspection on the 29 October 2019 (which was a continuation of the inspection process) 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 not 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 Dental Surgery is in Crumpsall, Manchester and provides NHS and private treatment to adults and children.

The practice is not accessible for people who use wheelchairs. On street parking is available near the practice.

The dental team includes two dentists, four dental nurses, a receptionist and a practice manager. The practice has three 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.

On the day of inspection, we collected 13 CQC comment cards filled in by patients and spoke with one other patient.

During the inspection we spoke with the principal dentist, two dental nurses, the receptionist 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 Thursday 9am to 5pm

Friday 9am to 1pm

Our key findings were:

  • The practice appeared clean and tidy. and well maintained.
  • The provider had infection control procedures which reflected published guidance.
  • Staff knew how to deal with emergencies. Medicines and life-saving equipment were not available in line with Resuscitation Council UK guidance.
  • Systems to identify and manage risks were ineffective.
  • The provider had safeguarding processes. Improvements were needed to ensure staff knew their responsibilities for safeguarding vulnerable adults and children and completed appropriate training.
  • Staff recruitment procedures required improvement. Disclosure and Barring Service checks were not carried out. No checks were in place for agency staff.
  • Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • Staff provided preventive care and supporting patients to ensure better oral health.
  • The appointment system took account of patients’ needs.
  • The provider asked staff and patients for feedback about the services they provided.
  • The provider had suitable information governance arrangements.

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

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulations the provider is not meeting are at the end of this report.

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

  • Take action to ensure the availability of an interpreter service for patients who do not speak English as their first language.
  • Take action to register the practice’s use of dental x-ray equipment with the Health and Safety Executive in line with the Ionising Radiation Regulations 2017 (IRR17).

31 January 2013

During a routine inspection

We visited The Dental Surgery on 31 January 2013 and found that the building was warm and clean and the staff treated patients with politeness and courtesy. We saw that there was a range of information in the reception area and posters promoting oral hygiene were displayed.

We saw that policies and procedures were accessible to staff and emergency medical equipment was in place. The surgery had contingency plans in place to be followed in the event of any emergency.

We looked at records, which were factual, up to date and relevant. Patients' medical information, treatment plans and personal preferences were regularly reviewed and updated. We looked at a sample of staff files and saw that they were suitably qualified for their roles and we saw that training and development were ongoing.

Decontamination processes were seen to be followed appropriately and hygiene procedures were adhered to by staff, to minimise the risk of cross infection.

We spoke with three members of staff who demonstrated an awareness of safeguarding issues and the processes to be followed.

We spoke with seven patients who were all positive about the service. One patient said 'The staff are attentive, respectful and always give advice that is understandable.' Another patient said 'The service is good, the treatment excellent.'

We observed that the quality of the service was continually monitored. Complaints were taken seriously and used to inform changes and improvements to the service.