Updated 18 November 2020
We undertook a follow up desk-based focused review of Broughton Dental Practice on 12 October 2020. This review was carried out to look at 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 review was led by a CQC inspector.
We undertook a comprehensive inspection of Broughton Dental Practice on 30 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 well led care and was in breach of regulations 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 Broughton Dental Practice on our website .
As part of this review 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 (requirement notice only). We then inspect again after a reasonable interval, focusing on the area(s) 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 breaches we found at our inspection on 30 September 2019.
We found this practice was providing well-led care in accordance with the relevant regulations.
Background
Broughton Dental Practice is in Broughton Astley, a large village located in the Harborough district of Leicestershire. It provides private dental treatment to adults and children.
There is level access for people who use wheelchairs and those with pushchairs through entry at the rear of the premises. There are some limited car parking spaces at the front of the premises and free public car parking is also available on street within close proximity.
The dental team includes two dentists, two dental nurses, one trainee dental nurse, two dental hygienists, one clinical dental technician, two receptionists and a practice manager. The practice has three treatment rooms, one is located on the ground floor.
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 Broughton Astley Dental Practice is the principal dentist.
During the review, we corresponded with the principal dentist 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, Wednesday, Thursday and Friday from 8.30am to 4.30pm and Tuesday from 8.30am to 7pm.
Our key findings were :
- Processes had improved in relation to staff completion of training such as safeguarding, which was completed to the expected level for clinical staff.
- Whilst an incident reporting policy had been implemented, this did not include a definition of a significant/untoward incident and how such incidents would be managed.
- Systems for incident reporting had improved. We were provided with examples which included how they had been addressed in the practice.
- The provider had completed training to assist them in undertaking audit activity. We were sent a sample of record keeping audits completed.
- Fixed wiring testing had been completed within the premises.
- We noted where actions had been taken to manage risk. For example, an external contractor had completed a fire risk assessment of the premises and lone working risks had been considered. We identified that a practice specific sharps risk assessment was required to be completed.
- Recommended emergency equipment had been obtained since our previous site visit.
- We were informed that rectangular collimators were fitted to X-ray equipment.
- Systems had improved in relation to the management of patient safety alerts.
- Tests were in place for one of the ultrasonic baths.
- Recruitment processes had been improved.
- Improvements had been made to dental record keeping.
- We were informed that the Mental Capacity Act and Gillick competence had been subject to discussion amongst staff.
- The practice did not have a hearing loop at the reception desk; we were informed that there were no immediate plans to obtain one.
There were areas where the provider could make improvements. They should:
- Improve the practice's risk management systems for monitoring and mitigating the various risks arising from the undertaking of the regulated activities. For example, implement a practice specific sharps risk assessment.
- Improve the practice’s arrangements for ensuring good governance and leadership are sustained in the longer term.