Updated 19 March 2020
We undertook a focused inspection of Highbury Dental Care on 18 February 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 remotely by a specialist dental adviser.
We undertook a comprehensive inspection of Highbury Dental Care on 16 September 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, effective or well led care and was in breach of regulations 12, 17 and 19 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 Highbury Dental Care on our website www.cqc.org.uk.
As part of this inspection we asked: Remove as appropriate:
• Is it safe?
• Is it effective?
• 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 breaches we found at our inspection on 16 September 2019.
Are services effective?
We found this practice was providing effective care in accordance with the relevant regulations.
The provider had made improvements in relation to the regulatory breaches we found at our inspection on 16 September 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 breaches we found at our inspection on 16 September 2019.
Background
Highbury Dental Care is in the Bulwell area of Nottingham and provides NHS and private treatment for adults and children.
There is level access to the practice for people who use wheelchairs and those with pushchairs and an automatic front door. Car parking spaces, including dedicated parking for people with disabilities, are available near the practice.
The dental team includes two dentists, three dental nurses who also had reception duties. The practice has three treatment rooms and centralised decontamination facilities.
The practice is owned by an organisation 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 Highbury Dental Care is one of the providers, they are not based at Highbury Dental Care.
During the inspection we spoke with the provider. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open: Monday: from 9am to 8pm, Tuesday to Thursday: from 9am to 5pm and Friday: from 9am to 2pm.
Our key findings were:
- The safeguarding policy had been reviewed and now clearly identified who was the safeguarding lead.
- Staff recruitment records were in accordance with Schedule 3 of the Health and Social Care Act 2008 Regulations.
- The fire risk assessment had been reviewed and outstanding actions had been completed.
- Since the last inspection in September 2019, radiography audits had been completed for all dentists working at the practice.
- The local rules for all X-ray machines had been reviewed and updated.
- There was evidence that every member of staff had been immunised against the Hepatitis B virus and had immunity.
- Medical emergency equipment had been reviewed and all equipment identified in national guidance was available.
- Risk assessments had been completed for each substance identifiable under the Control of Substances Hazardous to Health (COSHH) regulations.
- Since the last inspection in September 2019, two infection prevention and control audits had been completed.
- A tracking system for NHS prescriptions had been devised and was ready to be put into use.
- Antimicrobial audits had been completed in September 2019.
- The system for recording significant events had been reviewed and significant events discussed in a staff meeting with all staff.
- The arrangements for identifying sepsis had been reviewed. Posters were on display and staff had received training.
- A new dentist had been recruited to address the issue of cancelled appointments.
- Duty of candour policy was discussed with all staff in September 2019. A new policy had been introduced in January 2020.
- The system for audits had been reviewed, and two members of staff had been recruited to specifically complete audits within the organisation.