We undertook a focused inspection of 606 Dental Practice on 12 December 2018. 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 was supported by a specialist dental adviser.

We undertook a comprehensive inspection of 606 Dental Practice on 29 May 2018 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 606 Dental Practice 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. 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 not providing well-led care in accordance with the relevant regulations.

The provider had made some improvements in relation to the regulatory breach we found at our inspection on 29 May 2018.

Background

606 Dental Practice is in Solihull, West Midlands and provides NHS and private treatments for adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces, including those for blue badge holders, are available near the practice.

The dental team includes six dentists, six dental nurses (including one head nurse), two dental hygienists, one dental hygiene therapist, a part time practice manager and five receptionists. The practice has six treatment rooms.

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 one dentist, one dental nurse and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open: Monday to Friday 9am to 5.30pm.

Our key findings were:

• Staff were aware of the system for reporting incidents at the practice and recent incidents had been recorded.
• Evidence was available to demonstrate that policies and procedures were reviewed and updated.
• Patient dental records that we saw documented that either verbal or written consent to treatment had been obtained. Evidence was available to demonstrate that options, risks and benefits of treatment discussed with patients had been recorded in patient dental records.
• Disclosure and barring service checks were available for all staff.
• Up to date indemnity insurance was available for all members of clinical staff.
• Clinical staff had completed personal development plans to comply with clinical governance standards.
• The practice had reviewed its protocols for the use of dental dam for root canal treatment taking into account guidelines issued by the British Endodontic Society.

• The practice had reviewed its protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment.

• Complaint handling procedures had been reviewed and an accessible system for identifying, receiving, recording, handling and responding to complaints by service users had been established.
• The provider was using safe sharps in accordance with the Sharp Instruments in Healthcare Regulations 2013. Consideration should be given to the provision of additional equipment for the safe disposal of sharps.
• A five-year fixed wiring test had been completed. There was no evidence to demonstrate that issues for action identified had been addressed.

• Not all risk assessments seen contained correct information or information relevant to the practice; the sharps risk assessment did not record details of all sharp instruments in use at the practice. The lone worker policy recorded information that was not relevant to the practice and control measures that had not been implemented. The violence at work policy recorded control measures that had not been implemented.

• The practice was completing infection prevention and control audits on a six-monthly basis. An out of date audit tool was being used and some information recorded was incorrect.

• The practice’s systems for security of prescriptions was ineffective. The log of prescriptions was stored with prescription pads. Not all prescription pads had been logged. The practice’s prescription audit did not identify the prescribing patterns for individual dentists.

• Improvements had been made to induction processes in place, although further improvements were required.

We identified regulations the provider was not meeting. They must:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulation/s the provider is not meeting are at the end of this report.

We carried out this announced inspection on 29 May 2018 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 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 that this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

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

Are services caring?

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

Are services responsive?

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

Are services well-led?

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

Background

606 Dental Practice is in Solihull, West Midlands and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces, including those for blue badge holders, are available near the practice.

The dental team includes six dentists, six dental nurses (including one head nurse), two dental hygienists, one dental hygiene therapist, a part time practice manager and five receptionists. The practice has six treatment rooms.

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 received comments from 26 patients.

During the inspection we spoke with five dentists (including the principal dentist), four dental nurses, two dental hygienists and two receptionists. The practice manager was not available on the day of this inspection. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open: Monday to Friday 9am to 5.30pm.

Our key findings were:

• The practice appeared clean and well maintained.
• The practice had infection control procedures. Staff were not routinely following guidance and improvements were required to infection prevention and control practices.
• Staff knew how to deal with emergencies. Not all appropriate medicines and life-saving equipment were available but we were told that these were ordered following this inspection.
• The practice had systems to help them manage risk although significant improvements were required. One risk assessment seen had not been completed correctly. We requested but were not provided with a health and safety risk assessment.
• Staff knew their responsibilities for safeguarding adults and children. There was no evidence to demonstrate that safeguarding information had been reviewed recently and that contact details for local safeguarding authorities were checked to ensure they were up to date.
• The practice’s staff recruitment procedures required some improvement. Following this inspection, we were told that appropriate action had been taken to address issues identified during this inspection.
• Clinical staff provided patients’ care and treatment in line with current guidelines. Patient dental care records did not demonstrate that options, risks, benefits or consent were recorded on each occasion.
• Staff treated patients with dignity and respect. The door to one treatment room was left open whilst the dentist was with a patient. This did not protect their privacy. Following this inspection, we were sent a copy of a memorandum sent to all staff reminding them of the importance of respecting privacy.
• The practice was providing preventive care and supporting patients to ensure better oral health.
• The appointment system met patients’ needs.
• Staff felt involved and supported and worked well as a team.
• The practice asked patients for feedback about the services they provided, patients were encouraged to complete the NHS Friends and Family Test.
• Not all information was available to demonstrate that the practice dealt with complaints in a timely manner.

We identified regulations the provider was not meeting. They must:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

There were areas where the provider could make improvements. They should:

• Review the practice’s protocols for the use of rubber dam for root canal treatment taking into account guidelines issued by the British Endodontic Society.
• Review the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment.
• Review the practice's complaint handling procedures and establish an accessible system for identifying, receiving, recording, handling and responding to complaints by service users.
• Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.
• Review the practice’s infection control procedures and protocols taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’

We carried out an announced comprehensive inspection on 28 April 2015.

The practice provides primary dental services to mainly NHS patients. The practice is open Monday to Friday between the hours of 9.00am and 5.30pm. The practice is also open from 9.00am to 12.30pm on Saturdays.

The practice has six surgeries located on the ground floor and first floor with waiting rooms on each floor. The staff structure of the practice consists of the practice manager, an assistant practice manager who was also a registered dental nurse. There were six dentists (two full time and four part time) and six dental nurses who also work as receptionists and a head receptionist. The practice has the services of four dental hygienists (one locum), who carry out preventative advice and treatment on prescription from the dentist.

We spoke with four patients during the inspection. They told us that they were very satisfied with the services provided, that the dentists provided them with clear explanations about their care and treatment, that costs were clear and that all staff treated them with dignity and respect.

We viewed 47 CQC comment cards that had been completed by patients at the practice. All of them reflected positive comments about the staff and the services provided. Patients commented that the practice was clean and hygienic, they found it easy to book an appointment and they found the quality of the dentistry to be very good. They said explanations were clear and that the staff were kind, caring and reassuring. Patients also commented about the availability of a dentist when urgent treatment was required.

The CQC previously inspected the practice on September 2014 in response to anonymous information received. The specific concerns raised with the CQC were not substantiated. However, we found that patients were not protected from the risk of infection because appropriate guidance had not been followed. We also found recruitment procedures were not robust to ensure treatment and support was provided by suitably qualified, skilled and experienced staff. We asked the provider to send in an action plan outlining how they intended to make improvements.

At this inspection we checked that actions identified at our previous visit had been implemented and issues resolved. We had also received further anonymous information about the practice. We checked these areas of concern and found services being provided were safe, effective, caring, responsive and well-led care in accordance with the relevant regulations.

Our key findings were:

• The practice had a system in place to record, investigate and respond to significant events, safety issues and complaints.
• There were sufficient numbers of suitably qualified staff to meet the needs of patients
• Staff had been trained to handle emergencies and appropriate medicines were readily available.
• Infection control procedures were robust and staff were able to demonstrate how they followed the published guidance.
• Patient’s care and treatment was planned and delivered in line with evidence based guidelines, best practice and current legislation.
• Patients received clear explanations about their proposed treatment, costs, benefits and risks and were involved in decisions about it.
• Patients were treated with dignity and respect and confidentiality was maintained.
• The practice staff felt involved and worked as a team.

There were areas where the provider could make improvements and should:

• Ensure the Disability Discrimination Act (DDA) assessment is reviewed regularly and any action identified followed up.
• Document the sharing of learning from complaints and concerns with the wider team.
• Ensure feedback received from patients is regularly analysed with identified actions and responded to appropriately.
• Ensure arrangements in place for monitoring and improving the service is effective and robust.

We conducted an unannounced inspection to this dental practice as we had received anonymous concerns relating to various practice and safety issues. The visit was undertaken by two Care Quality Commission Inspectors and a dentist specialist adviser. We reviewed the concerns raised which fell under our regulatory remit.

We spoke with a senior dental nurse, the acting practice manager and two dentists. We reviewed records and inspected the premises.

We found that the radiation protection file contained documentation pertaining to the maintenance of the x-ray equipment used in the practice.

Patient records were completed in line with current guidelines. Although the storage of some paper records in the staff room required some improvement.

Infection control practices were not satisfactory. Personal protective equipment such as gloves and aprons were not available in all treatment rooms and we saw that where they were available staff did not always use them. One treatment room required maintenance work to enable infection prevention and control standards to be maintained.

Some refurbishment had been completed to areas of the practice which had been affected by a water leak. Further work is required to ensure that the building is suitably maintained.

Pre-employment checks were not robust and did not include employment references or fitness to work checks. Criminal records bureau checks (CRB) had been completed for all but one member of staff who worked at the practice. We were advised that this was in progress.

During our visit on 14 December we met with a senior dental nurse and a dentist. We also spoke with a dental nurse and a receptionist.

We spoke with seven people who attended the practice. People described the practice as being welcoming and friendly. People spoke very positively about the quality of the service they had received. One person told us, "I’m very satisfied with the treatment they have given me." Another said, “All the staff are understanding and patient.”

People we spoke with told us that everything was always explained to them. One person said, "They always clearly discuss the treatment options.”

During our visit we saw the practice was clean and tidy. Processes were in place to ensure that equipment was safe to use and high levels of cleanliness maintained.

The practice had processes in place to monitor people's views about the service offered. People told us they never had cause to complain about the service they had received. People told us they were satisfied with the service and had recommended it to family and friends. Many people had used the practice for over thirty years.