We carried out an announced comprehensive inspection at JM Worsley Dental surgery on 20 October 2017 and at this time a breach of a legal requirement was found.

After the comprehensive inspection the practice wrote to us and told us that they would take action to meet the following legal requirements set out under the Health and Social Care Act (HSCA) 2008: Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, Good Governance

On 12 April 2017 we carried out a focused review of this service under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The review was carried out to check whether the provider had completed the improvements needed and identified during the comprehensive inspection on 20 October 2016. 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 JM Worsley Dental Surgery on our website at cqc.org.uk

Our findings were:

We found that this practice was now providing well-led care in accordance with the relevant regulations. The improvements needed had been made.

Background

The practice offers private primary care dentistry to both adult patients and children. The practice is open Monday to Friday 9.30am - 5.30pm.

There are three dentists, two hygiene therapists, one hygienist, three qualified dental nurses, two trainee dental nurses and a receptionist.

The principal dentist is the registered provider. A registered provider is registered with the Care Quality Commission to manage the service. Registered providers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is run.

Our key findings were:

• The practice had completed a Legionella Risk Assessment in October 2016.

• The practice had completed audits for disability access, fire safety compliance and health and safety in October 2016.

• An Infection Prevention audit was completed on 25 October 2016 with the practice achieving 98% compliance.

• The electrical safety assessment of the building and a gas safety certificate were completed in December 2016.

The practice had also acted upon other recommendations:

• The practice was now registered with the appropriate bodies to receive patient safety and recall alerts

• The x-ray file had been updated to record the names of the Radiation Protection Advisor (RPA) and the Radiation Protection Supervisor (RPS) for the practice.

• The practice manager has developed an audit and equipment service calendar.

People we spoke with confirmed that the dentists, therapists and dental nurses always explained what they were going to do. We looked at the patient satisfaction survey results for 2012. Responses from this survey were all positive about the care and treatment patients' received, the environment, cleanliness and the attitudes of staff. All consultations were conducted in private in the treatment rooms. We saw staff speaking to patients in a respectful manner and staff we spoke with understood the requirements for privacy, dignity and confidentiality. The person who spoke with was able to tell us about their diagnosis and the treatment options available and what they had decided to do.

The practice had appropriate equipment to support people in the event of an emergency. The practice facilities were clean and well maintained with appropriate floor and surface coverings. One person told us; “I have no concerns regarding the cleanliness of the practice.” We found that staff received appropriate professional development and were able to obtain further qualifications. Staff confirmed they had on-going formal supervision and appraisal. We found that the practice had an effective system in place to enable them to regularly assess and monitor the quality of service that patient's received.