Archived: Dr Louise Southworth - Richmond Terrace

We carried out a follow-up inspection at Dr Louise Southworth - Richmond Terrace on 17 October 2017.

We had undertaken an announced comprehensive inspection of this service on the 25 January 2017 as part of our regulatory functions where a breach of legal requirements was found.

After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach. This report only covers our findings in relation to those requirements. We checked whether they had followed their action plan to confirm that they now met the legal requirements.

We reviewed the practice against one of the five questions we ask about services: are the services well led? You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dr Louise Southworth - Richmond Terrace on our website at www.cqc.org.uk.

We revisited Dr Louise Southworth - Richmond Terrace as part of this review and checked whether they now met the legal requirements. We carried out this announced inspection on 17 October 2017 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.

The inspection was led by a CQC inspector who had remote access to a specialist dental adviser.

• Is it well-led?

This question forms the framework for the areas we look at during the inspection.

Our findings were:

Are services well-led?

We found that this practice was providing well-led care in accordance with the relevant regulations.

Background

Dr Louise Southworth - Richmond Terrace is in Blackburn and provides NHS and private treatment to adults and children.

The practice is not accessible for people who use wheelchairs. Car parking spaces are available near the practice.

The dental team includes three dentists, eight dental nurses, one dental hygienist and two receptionists. The practice has four 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.

During the inspection we spoke with the principal dentist and a dental nurse. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Friday from 8:30am to 5:00pm

Our key findings were:

• Improvements had been made to the processes for reducing the risks associated with fire.
• Improvements had been made to the process for ensuring staff had completed training.
• Staff had completed training in safeguarding and the Mental Capacity Act.
• Records relating to service users were now stored securely.
• The recruitment process had been reviewed and all staff now had a Disclosure and Barring Service (DBS) check. We noted one dentist only had a basic check and the hepatitis B titre levels were not available for another dentist.

There were areas where the provider could make improvements and should:

• Review the practice's recruitment policy and procedures to ensure DBS checks are the correct level.

We carried out an announced comprehensive inspection on 25 January 2017 to ask the practice the following key questions; Are services safe, effective, caring, responsive and well-led?

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

Dr Louise Southworth Dental Practice is located in the centre of Blackburn. The practice predominantly provides an NHS service but patients can request private treatments. The practice has four dental surgeries over two floors. There are patient waiting areas on each floor. The premises has not been adapted for patients with a disability and does not provide access for wheelchair users.

The practice is open from 8.30am - 5.00pm Monday to Friday.

The practice owner is registered with the Care Quality Commission (CQC) as an individual. Like registered providers, they are ‘registered persons’. Registered persons 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 three CQC comment cards on the day of our visit and spoke with two patients during the inspection. Patients spoke positively about the staff and the care and treatment they received. Patients commented they were made to feel at easy by lovely staff. They said staff were attentive and polite.

Our key findings were:

• An infection prevention and control procedure was in place.
• The sterilisation of dental instruments followed Department of Health guidance.
• The practice had systems for recording incidents, accidents and significant events.
• Dental professionals provided treatment in accordance with current professional guidelines.
• A process was established to seek patient feedback about the service.
• Patients could access urgent care when required.
• A process was in place for managing complaints.
• The practice provided oral health education to children.
• Patients received explanations about their proposed treatment, costs, benefits and risks, and were involved in making decisions about their treatment.
• Staff received annual medical emergency training.
• Not all equipment for dealing with medical emergencies reflected the guidance from the Resuscitation Council (UK).
• Recruitment checks to ensure staff were suitable to work with vulnerable patients had not been undertaken for all staff.
• The requirements of the fire assessment were not being followed, including routine checks of fire equipment and systems to minimise the risk of fire.
• Not all dental practitioners had routine chairside support when treating patients.
• Not all staff had completed safeguarding training and some staff had not completed the correct training level for their role.
• The governance system was not effective as risk assessments and audits had not identified concerns we found.
• Patient paper records were not stored in accordance with the NHS Code of Practice for records management.
• Products assessed as potentially hazardous to health were not always stored securely.

There were areas where the provider could make improvements and must:

• Ensure the practice's recruitment policy and procedures are suitable and the recruitment arrangements are in line with Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 to ensure necessary employment checks are in place for all staff and the required specified information in respect of persons employed by the practice is held.
• Ensure an effective system is established to assess, monitor and mitigate the various risks arising from the undertaking of the regulated activities. This should include a review of the reliability of the current approach to audit.
• Ensure the storage of records relating to people employed and the management of regulated activities is in accordance with current legislation and guidance.
• Ensure that all staff undertake child and adult safeguarding to appropriate level for their role.
• Ensure staff awareness of the Gillick competency and their responsibilities.
• Ensure staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and their responsibilities under the Act as it relates to their role.

There were areas where the provider could make improvements and should:

• Review the availability of equipment to manage medical emergencies giving due regard to guidelines issued by the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.
• Review the practice’s infection control procedures and protocols giving due regard to guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.
• Review the storage of products identified under Control of Substances Hazardous to Health (COSHH) 2002 Regulations to ensure they are stored securely.
• Review the protocols and procedures for use of X-ray equipment giving due regard to guidance notes on the Safe use of X-ray equipment.
• Review the protocols and procedures to ensure staff are up to date with their training and their Continuing Professional Development.
• Review the arrangements for chairside support when staff are treating patients.