Mr Imran Azmat - Birchfield Road

Updated 24 October 2016

We carried out a review of this service on 29 September 2016 to check that improvements to meet legal requirements planned by the practice after our compressive inspection on 3 November 2015 had been implemented. We reviewed the practice against one of the five questions we ask about services: Is the service well-led? This is because the service was not previously meeting some of their legal requirements under the well-led domain.

We undertook this review to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements.

The review was led by a CQC inspector who had access to remote advice from a specialist advisor.

During our review we checked that the registered provider’s action plan had been implemented. We reviewed a range of documents provided by the registered provider. We found that the practice was meeting their legal requirements under the well-led domain.

Updated 24 October 2016

We carried out an announced comprehensive inspection on 3 November 2015 as part of our regulatory function where a breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach.

We carried out a focussed review on 29 September 2016 to check whether the practice had taken action to address a breach of Regulation 17(1) and (2)(a)(b)(c)(f) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This report only covers our findings in relation to those requirements. We have not revisited Mr Imran Azmat – Birchfield Road for this review because the registered provider was able to demonstrate that they were meeting the standards without the need for a visit. You can read the report from our previous comprehensive inspection by selecting the ‘all reports’ link for Mr Imran Azmat – Birchfield Road on our website at www.cqc.org.uk

Our findings were:

Are services well-led?

We found that this practice was providing well-led care in accordance with the relevant regulations.

Our key findings were:

• Overall we found that sufficient action had been taken to address the shortfalls identified at our previous inspection and the provider was now compliant with the regulation.

There were areas where the provider could make improvements and should:

• Review the practice’s systems for completing checks on emergency equipment and medicines giving due regard to guidelines issued by the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.

• Review the current legionella risk assessment and implement the required actions, giving due regard to Health Technical Memorandum 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance