Bishopton Lane

We undertook a follow up inspection on 7 January 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 Bishopton Lane dental practice on 18 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 Bishopton Lane 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 breaches we found at our inspection on 18 June 2019.

Background

Bishopton Lane dental practice is in Stockton on Tees and provides predominantly NHS treatment, and some private treatment, to adults and children. The dental practice was built in 2010 and has two treatment rooms on the first floor. People who use wheelchairs and those with pushchairs can enter the premises via a small step at the front entrance. Advice regarding the lack of a ground floor treatment room is provided to patients at the time of booking appointments. Car parking spaces are available near the practice.

The dental team is comprised of a principal dentist, two dental nurses, a practice manager who is also a qualified dental nurse, two dental therapists and a receptionist.

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.

Monday to Thursday 9am to 5pm

Friday 9am to 4pm

Our key findings were:

• Improvements had been made to infection control procedures, staff understanding of decontamination procedures had improved. The decontamination room met relevant guidance.
• Emergency medicines and life-saving equipment were in line with Resuscitation Council UK standards.
• Improvements had been made to the storage of clinical waste and the risk management of sharps.
• Improvements had been made to the risk management of fire and electrical safety, hazardous substances and evidence of immunity to Hepatitis B.
• Effective monitoring of systems regarding Legionella were in place. The designated lead had completed legionella training.
• The practice had taken account of the needs of patients with disabilities to comply with the requirements of the Equality Act 2010. An assessment with action plan was in place.

We carried out this announced inspection on 18 June 2019 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. This 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 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

Bishopton Lane dental practice is in Stockton on Tees and provides predominantly NHS treatment, and some private treatment, to adults and children. The dental practice was built in 2010 and has two treatment rooms on the first floor. People who use wheelchairs and those with pushchairs can enter the premises via a small step at the front entrance. Advice regarding the lack of a ground floor treatment room is provided to patients at the time of booking appointments. Car parking spaces are available near the practice.

The practice is currently undergoing renovation and the provider has a plan to incorporate the empty building next door to create a ground floor surgery for easier access.

The dental team is comprised of a principal dentist, two dental nurses, a practice manager who is also a qualified dental nurse, two dental therapists and a receptionist.

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 35 CQC comment card filled in by patients. These provided a positive view of the practice.

During the inspection we spoke with the principal dentist, the practice manager, two dental nurses, and the receptionist.

The practice is open:

Monday to Thursday 9am to 5pm

Friday 9am to 4pm

We looked at practice policies and procedures and other records about how the service is managed.

Our key findings were:

• The practice appeared clean and was undergoing refurbishment.
• The provider had infection control procedures which did not reflect published guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were not available in accordance with published guidance. Missing items were ordered by the provider when we brought this to their attention.
• The practice had some systems to help them manage risks. The provider should review their systems for assessing and controlling the risks associated with fire, electrical safety, hazardous substances, Hepatitis B and dispensing of prescriptions.
• The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The provider had staff recruitment procedures in place. They should review the consistency of these, in particular for undertaking Disclosure and Barring Service (DBS) checks in relation to staff
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• Staff were providing preventive care and supporting patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• The provider should review their practice leadership to ensure it promotes a culture of monitoring for continuous improvement.
• Staff felt involved and supported and worked well as a team.
• The provider asked staff and patients for feedback about the services they provided.
• The provider dealt with complaints positively and efficiently.
• The provider had suitable information governance arrangements.

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

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

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

• Review the practice's responsibilities to take into account the needs of patients with disabilities and to comply with the requirements of the Equality Act 2010.