Updated 3 June 2021
We undertook a follow up focused inspection of Whitby Dental Care on 29 April 2021. 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 and the CQC senior national professional dental advisor.
We undertook a comprehensive inspection of Whitby Dental Care on 16 March 2021 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 and well led care and was in breach of Regulation 12(1) 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 Whitby Dental Care on our website www.cqc.org.uk.
As part of this inspection we asked:
• Is it safe?
• Is it well-led?
Our findings were:
Are services safe?
The provider had made improvements in relation to the conditions imposed to suspend regulated activities at the location on 19 March 2021.
Are services well-led?
The provider had made improvements in relation to the conditions imposed to suspend regulated activities at the location on 19 March 2021.
Background
Whitby Dental Care is in Whitby, North Yorkshire and provides NHS and private dental care for adults and children.
There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice at local car parks for a fee.
At the time of inspection, the dental team included two dentists (one of whom was not present during the inspection), one chairside support staff member, who was waiting to commence dental nurse training, and a receptionist. The team was supported on the inspection day by a practice manager and a lead dental nurse from a sister practice. The provider and registered manager were also present during the inspection.
The practice has four treatment rooms.
The practice is owned by a company and as a condition of registration must have a person registered with the CQC 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 Whitby Dental Care is one of the company partners.
During the inspection we spoke with all staff present at the time of inspection. We reviewed systems, processes and procedures to assess where improvements to how the service is managed had been made.
The practice is open: Monday to Friday 9am – 5pm.
Our key findings were:
- The provider had taken into account guidance issued by Public Health England (PHE) in respect to Covid-19.
- The practice’s Infection prevention and control systems and procedures were completed in line with The Health Technical Memorandum 01-05: Decontamination in primary care dental practices, (HTM 01-05), published by the Department of Health and Social Care.
- The legionella management system was improved but required further attention to ensure it was fully effective and embedded.
- The provider had reviewed recruitment, training and the monitoring of associated staff records; sharps risk and Hepatitis B risk mitigation required further attention to ensure they were fully effective and embedded.
- Systems to review and investigate when things went wrong had improved but required further attention to ensure they were fully effective and embedded.
- Staff felt involved and supported to work as a team. Staff were confident their concerns would be heard without fear of recrimination.
- Information governance arrangements were not in place in respect to the use of CCTV.
- Staff were not aware of the role and responsibility associated with being named as the Radiation Protection Supervisor.
- Systems were in place to provide effective staffing.
- The proposed systems to ensure effective leadership, governance and oversight of on-site management had improved and required monitoring and embedding.
We identified regulations the provider was not meeting. They must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Full details of the regulation the provider is not meeting are at the end of this report.
There were areas where the provider could make improvements. They should:
- Review the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment. In particular: Review the location of isolation switch and the clinician’s knowledge and awareness of the role of Radiation Protection Supervisor (RPS).