Updated 21 November 2019
We undertook a follow up desk-based inspection of Fern Cottage Dental Practice on 14 October 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 had remote access to a specialist dental adviser.
We undertook a comprehensive inspection of Fern Cottage Dental Practice on 19 June 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 well led care and was in breach of regulation 17 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 Fern Cottage Dental Practice on our website www.cqc.org.uk.
As part of this inspection we asked:
• 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 19 June 2019.
Background
Fern Cottage is in Barnsley and provides NHS and private treatment to adults and children.
There is ramp access at the rear of the property for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice on local side roads.
The dental team includes six dentists, five dental nurses (one of whom is a trainee), one receptionist and a practice cleaner. 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.
We reviewed documents that the provider submitted, including written and photographic evidence, to confirm the improvements made since our last visit on the 19 June 2019.
The practice is open: Monday to Friday 9am – 5pm.
Our key findings were:
- The process in place to review the effectiveness of the Hepatitis B vaccination for clinical staff was now effective.
- Fire safety management checks were more effective and were now monitored to ensure compliance. Action was taken to address the ill-fitting front door and uneven pathway into the practice.
- Dental materials which could be considered hazardous to health were now kept in a secured area.
- An improved system was now in place to ensure all relevant patient safety alerts were recorded, retained and acted upon when necessary.
- Improvements had been made to the existing staff induction procedures.
- Staff files and dental care records were now kept securely in line with the General Data Protection Regulations (GDPR).
- Appropriate measures had been taken to repair the damaged dental unit tubing and dental stool.
- Audit systems for infection prevention and control were brought in line with recognised guidance.
- The practice’s complaints procedure and policy was reviewed and updated to reflect changes made.