CQC Inspection Weaknesses

There are five key questions that CQC may refer to during inspections.

 

Areas of Weaknesses from CQC Reports - Fundamental Standards

The areas listed below have been indicated by CQC within dental practice's as areas that require improvements. Depending on the severity of the improvements depends on the time scale CQC will allow for this improvement to be implemented. There has recently been alot of cases where improvement have been required and the CQC has allowed 10 days for these improvements to take place.

  • Ensure audits of x-rays are completed at 12 monthly intervals. ISOPHARM TIP: The practice must monitor the quality of dental x-rays on a regular basis. This is to ensure that the standards of the x-rays are of a high standard and that patients do not receive unnecessary exposure to radiation. Annual radiography audits should be undertaken for each individual clinician. The findings should be discussed during practice meetings and peer review meetings.
  • Ensure immunisation evidence against Hepatitis B is available at all times. ISOPHARM TIP: Under HTM 01-05 (Section 2 K.iii.S) Staff involved in deontamination should demonstrate current immunisation for hepatitis B and, subject to local policy, Tetanus.
  • Ensure a Legionella Risk Assessment is carried out. ISOPHARM TIP: It is recommended that a Legionella Risk Assessment is carried out by a competent and responsible person. HTM0105 says’ The Health & Safety Commission’s Approved Code of Practice L8 gives practical advice on how to comply with UK health and safety law with respect to the control of Legionella bacteria. This Code is important in that it has a special legal status. If a healthcare organisation is prosecuted for a breach of health and safety law, and it is held that it did not follow the relevant provisions of the Code, that organisation would need to demonstrate that it had complied with the law in some other way, or a court would find it at fault'.
  • Store all medicines that need to be kept in the refrigerator and temperature log is kept-glucagon. ISOPHARM TIP: Some medications indicate the need to be kept refrigerated. In this instance a separate medical refrigerator is required. Regular temperature checks must be undertaken to ensure the temperature does not rise above 8 degrees. If the medication is not kept chilled it may affect the expiry date of the drug and effectiveness of the medication when delivered to a patient.
  • Carry out a Disability Discrimination 2005 Audit. ISOPHARM TIP: The Equality Act 2010 prevents the unlawful discrimination of all people. Dental practices have a general duty of care to make provisions for service users and employees should they have a disability. A risk assessment should be undertaken to assess the accessibility to the service and workplace. HSE say ‘Equality law recognises that bringing about equality for disabled people may mean changing the way employment is structured, the removal of physical barriers and/or providing extra support for a disabled worker.  This is the duty to make reasonable adjustments. The aim of the duty is to make sure that, as far as is reasonable, a disabled worker has the same access to everything that is involved in doing and keeping a job as a non-disabled person’