We undertook a focused inspection of Acle dental surgery on 19 March 2019. 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 dental specialist advisor.

We undertook a comprehensive inspection of the practice on the 12 June 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 Acle dental surgery on our website www.cqc.org.uk.

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 areas where improvement was required.

As part of this inspection we asked:

• Is it well-led?

Background

Acle Dental Surgery provides mostly private treatment to about 3,000 patients. It also provides some general dental and orthodontic treatment to children commissioned by the NHS. The practice opens on Monday to Thursday from 9am to 5pm, and on Fridays from 9am to 12.30pm. It opens till 7pm on alternate Monday and Wednesday evenings.

There is ground floor level access for people who use wheelchairs and those with pushchairs.

The dental team includes one dentist, and a visiting orthodontist, a dental hygienist, an implantologist and an endodontist. There are three dental nurses and one receptionist. The practice has two 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 the principal dentist, the dental nurse and the receptionist. We looked at practice policies and procedures and other records about how the service is managed.

Our findings were:

We found this practice was not providing well-led care in accordance with the relevant regulations. Although there had been improvement in many areas, leadership and oversight of safety within the practice was still not effective and the provider had not addressed some of the shortfalls we had identified at our previous inspection in a timely way.

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

We carried out this announced inspection on 12 June 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 this practice was providing safe care in accordance with the relevant regulations, although improvements could be made.

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

Acle Dental Surgery provides mostly private treatment to about 3,000 patients. It also provides some general dental and orthodontic treatment to children commissioned by the NHS. The practice opens on Monday to Thursday from 9am to 5pm, and on Fridays from 9am to 12.30pm. It opens till 7pm on alternate Monday and Wednesday evenings.

There is ground floor level access for people who use wheelchairs and those with pushchairs.

The dental team includes one dentist, and a visiting orthodontist, a dental hygienist, an implantologist and an endodontist. There are three dental nurses and one receptionist. The practice has two 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 collected 38 CQC comment cards filled in by patients and spoke with three other patients.

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

Our key findings were:

• We received positive comments from patients about the dental care they received and the staff who delivered it.

• The appointment system met patients’ needs and the practice opened late on alternate Mondays and Wednesdays. Text appointment reminders were available.

• The practice was clean and well maintained, and had infection control procedures that mostly reflected published guidance, although improvements could be made.

• Staff felt involved and supported and worked well as a team.

• There was no robust system in place to ensure that untoward events were analysed and used as a tool to prevent their reoccurrence.

• Systems to ensure the safe recruitment of staff were not robust, as essential pre-employment checks had not been completed.

• Risk assessment was limited and recommendations to improve safety for patients and staff were not always implemented.

• Patient dental care records did not reflect standards set by the Faculty of General Dental Practice regarding clinical examinations and record keeping. Written consent was not always obtained for some invasive procedures.

• Audit and quality assurance systems were limited.

• Dental nursing staff assisting with implant procedures had not received suitable training for their role.

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.

A full detail of the regulation the provider was not meeting is at the end of this report.

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

• Review the storage of dental care products and medicines requiring refrigeration to ensure they are stored in line with the manufacturer’s guidance and the fridge temperature is monitored and recorded.

• Review the practice’s protocols for recording in the patients’ dental care records the reason for taking the X-ray and quality of the X-ray giving due regard to the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2000.

• Review the practice’s sharps procedures and ensure the practice follows the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

• Regularly monitor and record water temperatures as part of the Legionella risk assessment taking into account guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices.

• Review the practice's responsibilities to the needs of people with a disability, including those with hearing difficulties and those who do not speak English and the requirements of the Equality Act 2010.

• Review staff training so that dental nurses assisting with implant treatment receive appropriate training.

During this inspection we spoke with four staff and an independent dental adviser from NHS England who had visited the service. We found that most of the improvements planned by the provider had been completed to achieve and maintain compliance with the essential standards we inspected. Further structural work was planned to ensure that the decontamination room met best practice standards.

People had access to information about the service, about common dental conditions and dental health promotion. We saw samples of the responses from people to a recent satisfaction survey, which were almost exclusively positive. Some people made additional positive comments, such as, “Best dentist I have been to.”

People expressed their views and were involved in making decisions about their care and treatment as demonstrated by their records. They were asked for information about their medical history and this was documented annually.

Records showed that all staff had completed training in safeguarding children and vulnerable adults. Information about safeguarding, including how to raise a concern with the local authority, was available to staff.

There were effective systems in place to reduce the risk and spread of infection. A nurse lead had been appointed and policies and procedures were followed by staff.

The provider had developed systems to effectively monitor the quality and safety of the service. This included regular checks and audits.

There was limited information available regarding dental health promotion and the practice information leaflet contained inaccurate and out of date information. This meant that people were not supported with the relevant information in order to be involved in their dental care and treatment.

Those dental treatment records seen were incomplete and lacked clear information about consent, medical history and the treatment given during each consultation. This showed us that people did not always experience care, treatment and support that met their needs and protected their rights.

The provider had not made suitable arrangements to ensure that staff had received updated training in the safeguarding of vulnerable adults and children. This meant that people who use the service were not protected from the risk of potential abuse.

The provider had not made suitable arrangements to implement current infection prevention and control guidance. This meant that people who used the service were not protected from the risk of infection.

There was no audit framework in place, and no patient survey had been carried out recently. This meant that the provider did not have an effective system to assess and monitor the quality of service provided.

Although we found non-compliance in all the regulations assessed, the provider acknowledged this during the inspection and is being assisted to address these concerns by the NHS dental practice adviser service.