A Blackburn dental practice has been told is needs to improve risk management and its adherence to published guidance.
Ewood House Dental Surgery in Bolton Road was visited by the Care Quality Commission (CQC) in October, with a report into their findings published last week.
Though regulations were being met in most areas the CQC found the practice “was not providing well-led care in accordance with the relevant regulations.”
The report said the registered person at the practice had systems or processes that “operated ineffectively” in that they failed to enable them to assess, monitor, and improve the quality and safety of the services being provided.
This was also said in relation to risks relating to health, safety, and welfare of service users who may be at risk, resulting in a breach of Regulation 17 of the Health and Social Care Act 2008.
The published report said: “The assessment highlighted areas where improvements were needed, such as risk management and adherence to published guidance.
“Improvements should be made to the oversight of the leadership team to ensure that the practice’s clinical governance systems and processes were followed and risks managed appropriately.
“The practice’s information governance arrangements needed improvements to ensure all patients’ electronic care records were password protected when the computer was not in use and that paper records were stored securely to comply with General Data Protection Regulations (GDPR).
“On the day we saw patient records were not consistently stored securely and were accessible to unauthorised persons.
“Improvements were needed to ensure processes for managing risks were effective. The practice did not have adequate systems in place for identifying, assessing and mitigating risks in areas such as the completion of risk assessments, recruitment, medicines management and legionella.
“The practice’s systems and processes for learning, quality assurance and continuous improvement, needed improvements to ensure audits undertaken were a reflection of the current protocols at the practice.
“The audits had not identified the required improvements highlighted within our assessment.
“However, the information and evidence presented during the inspection process was clear and well documented. The practice’s policies, protocols and procedures were accessible to all members of staff.
“Audits were undertaken according to recognised guidance. Staff were aware of the importance of protecting patients’ personal information. The practice had systems to review and investigate incidents and accidents, and for receiving and acting on safety alerts.
“The practice responded to concerns and complaints appropriately. Staff discussed outcomes to share learning and improve the service.”
The report did highlight that staff liked working at the practice and they “felt like a family.”
They also said patients were “treated with dignity and respect,” that care and treatment was provided in line with current guidance, and that infection control procedures were in place.”
The CQC said it has asked for an action plan in response to the concerns.