The Care Quality Commission
  • Dentist
  • Dentist

The Dental Surgery

156 Old Kent Road, London, SE1 5TY (020) 7703 9922

Provided and run by:
Dr May Jouaid Amour

Important: The provider of this service changed. See old profile

All Inspections

13 May 2021

During an inspection looking at part of the service

We undertook a focused follow up inspection of The Dental Surgery on 13 May 2021 which included a review of evidence submitted to us by the provider before the site visit. 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 had remote access to a specialist dental advisor.

We undertook a follow-up inspection of The Dental Surgery on 10 November 2020 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 The Dental Surgery 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 (requirement notice only). We then inspect again after a reasonable interval, focusing on the area 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 10 November 2020.

Background

The Dental Surgery is in the London Borough of Southwark and provides NHS and private treatment for adults and children.

The dental team includes the principal dentist and a trainee dental nurse. The practice has one treatment room.

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

The practice is open between 10.00am and 5.00pm - Monday to Friday (Wednesday closed)

Our key findings were:

  • Recommendations from the Legionella risk assessment had been actioned.

  • Infection prevention and control audits were completed accurately.

  • Regular checks on medicines and equipment were undertaken.

  • Improvements were made to maintain accurate, complete and contemporaneous records in respect of each patient.

  • There were effective systems for the on-going identification of learning and development needs, training, assessment, supervision and appraisal of all staff.

10 November 2020

During an inspection looking at part of the service

We undertook a focused inspection on 10 November 2020 which included a review of evidence submitted to us by the provider before the site visit. 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 the practice was now meeting legal requirements.

The inspection was led by a CQC inspector who was supported by a second CQC Inspector.

We undertook a comprehensive inspection of The Dental Surgery on 16 January 2020 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 or Well led care and was in breach of Regulations 12, 17, and 18 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 The Dental Surgery on our website www.cqc.org.uk.

As part of this inspection we asked:

• Is it safe?

• 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 areas where improvement was required.

Our findings were:

Are services safe?

We found this practice was providing safe care in accordance with the relevant regulations.

The provider had made improvements in relation to the regulatory breach we found at our inspection on 16 January 2020.

Are services well-led?

We found this practice was not providing well-led care in accordance with the relevant regulations.

The provider had made some but not sufficient improvements to put right the shortfalls and had not fully responded to the regulatory breach we found at our inspection on 16 January 2020.

Background

The Dental Surgery is in the London Borough of Southwark and provides NHS and private treatment for adults and children.

The dental team includes the principal dentist and a trainee dental nurse. The practice has one treatment room.

The practice is owned by an individual who is the principal dentist. 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 the trainee dental nurse. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open between 8.45 am and 5.00 pm - Monday to Friday.

Our key findings were:

  • A dental sharps risk assessment had been carried out, and training in the handling and disposal of dental sharps had been completed by staff.

  • Risk assessments and information relating to the Control of Substances Hazardous to Health Regulations 2002 (COSHH) was available to staff.

  • An automated external defibrillator (AED) was available for use in the event of a medical emergency and staff had completed training in basic life support. However improvements were needed for monitoring emergency medicines and equipment.

  • Systems had been implemented to ensure that patient referrals were monitored and followed up.

  • The provider had implemented an effective system for receiving and responding to patient safety alerts, recalls and rapid response reports issued by the Medicines and Healthcare products Regulatory Agency (MHRA), the Central Alerting System and other relevant bodies, such as Public Health England.

  • Inspection and servicing of the fire alarm system had been carried out on 3 March 2020.

  • A five-year electrical fixed wiring safety check was undertaken on 16 February 2020.

  • Portable Appliance Testing (PAT) had been carried out on 14 February 2020.

  • A legionella risk assessment had been carried out on 4 March 2020; however not all recommendations had been actioned.

  • Infection prevention and control audits were not being completed accurately in all instances.

  • There were ineffective systems for the on-going identification of learning and development needs, training, assessment, supervision and appraisal of all staff.

  • Improvements were still required to maintain accurate, complete and contemporaneous records in respect of each service user.

16 January 2020

During a routine inspection

We carried out this announced inspection on 16 January 2020 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 Care Quality Commission, (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 this practice was not providing safe care in accordance with the relevant regulations.

Are services effective?

We found this practice was providing effective care in accordance with the relevant regulations.

Are services caring?

We found this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found this practice was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found this practice was not providing well-led care in accordance with the relevant regulations.

Background

The Dental Surgery in the London Borough of Southwark and provides NHS and private dental care and treatment for adults and children.

The dental team includes the principal dentist and two trainee dental nurses. The practice has one treatment room.

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 ten CQC comment cards filled in by patients and spoke with four other patients.

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

The practice is open between 8.45am and 5pm on Monday to Fridays:

Our key findings were:

  • The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • The provider had staff recruitment procedures which reflected current legislation.
  • Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • The appointment system took account of patients’ needs.
  • The provider asked staff and patients for feedback about the services they provided.
  • The provider dealt with complaints positively and efficiently.
  • The provider had information governance arrangements.
  • The clinical staff provided patients’ care and treatment in line with current guidelines. Improvements were needed so that detailed records were maintained in respect of patient assessment and treatments carried out.
  • Improvements were needed to ensure that the practice is visibly clean and well-maintained.
  • The provider had infection control procedures which reflected published guidance. However these were not adhered to consistently.
  • Staff knew how to deal with emergencies. Some life-saving equipment was not available on the day of the inspection. This was made available following our inspection.
  • There were ineffective systems to help assess and manage risk to patients and staff.
  • The provider had ineffective leadership to support a culture of continuous improvement.
  • There were ineffective systems to monitor staff learning needs and to ensure that they understood and followed relevant guidance, policies and procedures.

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

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties

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

6 December 2013

During a routine inspection

People we spoke with told us they were happy with the service they received. They said that the dentist and staff were helpful and friendly. One person said, "The dentist involves me in discussions about the treatment and I'm very comfortable here. The staff are lovely and they do a good job."

People had their treatment and charges explained to them in a way they understood. They felt able to ask questions about their treatment to ensure they knew what to expect. One person told us, "The dentist always tells me what treatment needs to be done and gives me clear advice about after care."

There were arrangements in place for the decontamination of dental instruments and equipment. However, there some shortfalls in these arrangements and national guidelines were not being followed in all respects, which could place people at risk.

Staff were appropriately supported through thorough induction, training and development. Supervision was informal but there was a formal appraisal system.

There was an effective complaints process in place.