Updated 15 August 2017
We carried out an announced comprehensive inspection of this practice on 31 March 2016. A breach of legal requirement was found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to Regulation 17 HSCA (RA) Regulations 2014 Good Governance.
We undertook a focused inspection of Marsh Hill Dental Surgery on 18 July 2017. This was to follow up on actions we asked the provider to take after our announced comprehensive inspection.
This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Marsh Hill Dental Surgery on our website at www.cqc.org.uk
Our findings were:
Are services well-led?
We found that this practice was providing well-led care in accordance with the relevant regulations.
Background
Marsh Hill Dental Surgery Centre is a general dental practice which offers predominantly NHS and some private dental treatment to adults and children.
The premises are located on the ground floor and consist of one treatment room and a reception/waiting area. The decontamination of dirty dental instruments is carried out in the treatment room as the practice does not have a designated decontamination room.
The practice is open Mondays and Tuesdays from 9am to 3pm, on Thursdays it is open from 9am to 2pm and on Fridays it is open from 9am to 1pm. On Wednesdays reception is open for bookings only from 9am to 1pm.
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 practice manager and the dental nurse. We looked at practice policies and procedures and other records about how the service is managed.
Our key findings were:
- Improvements were seen in most areas where concerns had been highlighted in our previous comprehensive inspection.
- The practice’s recruitment policy, procedures and the recruitment arrangements had been reviewed.
- The practice had put processes in place to establish a system to assess, monitor and mitigate the various risks arising from undertaking the regulated activities.
There were areas where the provider could make improvements and should:
- Review the condition of flooring, cabinetry and fittings and ensure that repairs and replacements are incorporated into future refurbishment plans. The practice should arrange to promptly carry out remedial repairs until the refurbishment.
- Review their cleaning schedules and the effectiveness of these in the practice.