Updated 27 October 2020
We undertook a follow up desk-based review of High Street Dental Practice on 30 September 2020. This review was carried out to examine 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 High Street Dental Practice on 30 July 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 High Street Dental Practice on our website .
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 (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 breach we found at our inspection on 30 July 2019.
Background
High Street Dental Practice is in Bedford and provides mostly NHS and some private treatment to adults and children. Services include general dentistry and dental implants.
There is level access for people who use wheelchairs and those with pushchairs. There are no car parking facilities, these are available in local car parks within close proximity to the practice. They include car parking spaces for blue badge holders.
The dental team includes four dentists, four dental nurses who also undertake reception duties and a practice manager who also covers reception when required. The practice has three treatment rooms in use, all on ground floor level.
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.
During the review, we looked at practice policies and procedures and other records about how the service is managed.
The practice is open: Monday to Friday from 8.45am to 5.30pm.
Our key findings were:
- Significant event reporting had been subject to discussion by staff within the practice.
- Monitoring arrangements had been improved to identify when staff training was due for completion.
- There was evidence that recruitment processes had improved which was demonstrated when a new staff member was appointed.
- The practice’s emergency equipment kit had been replenished to ensure that it reflected the Resuscitation Council Guidelines.
- Whilst there was a sharps risk assessment, this required review to ensure it reflected the specific sharps used within the practice and the individual control measures.
- Fixed wiring testing had been undertaken, including follow up remedial work required as a result.
- Hepatitis B information had been obtained for a member of the team.
- Rectangular collimators had been obtained for X-ray equipment in use.
- Patient records held in paper form were now secured.
- The Mental Capacity Act had been subject to some discussion amongst staff.
- Patient referrals made were subject to monitoring.
- The practice reception desk had been lowered; the practice had yet to implement other actions identified in an Equality Act audit previously completed.
- Infection prevention control audits were not being completed with the recommended frequency as advised in national guidance.
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. In particular, review national guidance regarding the recommended frequency of infection and prevention control audits and ensure that the sharps risk assessment is specific to the types of sharps held within the practice.
- Improve the practice’s arrangements for ensuring good governance and leadership are sustained in the longer term. For example, the implementation of comprehensive policy in relation to significant events and monitoring actions to be taken as identified in audit.