We visited Alexandra Dental Practice for a follow-up inspection on 8 February 2017.

We had undertaken an announced comprehensive inspection of this service on 4 July 2016 as part of our regulatory functions where a breach of legal requirements was found.

After the comprehensive inspection the practice wrote to us with an action plan to say what they would do to meet the legal requirements in relation to the breach.

We visited the practice to check that they had followed their plan and to confirm that they now met the legal requirements.

We reviewed the practice against one of the five questions we ask about services: is the service well-led? 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 Alexandra Dental Practice on our website at www.cqc.org.uk.

We carried out an announced comprehensive inspection on 04 July 2016 to ask the practice the following key questions; Are services safe, effective, caring, responsive and well-led?

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

Alexandra Dental Practice is located in Epsom, Surrey. The practice is based on the ground level of a residential property. There are two treatment rooms, a decontamination room, a reception area, a large waiting room, a patient toilet, an office and a staff room with a kitchen. The practice also has an outside staff toilet and a lockable shed that is used for storing clinical waste.

The practice provides mainly NHS dental services to adults and children and has a small list of patients that receive private treatment. The practice offers a range of dental services including routine examinations and treatment, crowns, dentures and bridges.

The practice staffing consisted of two dentists, two dental nurses, a dental hygienist, a receptionist and a financial business manager. One of the dentists is the provider and the dental hygienist has been the acting practice manager since September 2015.

The practice opening hours are Monday to Friday 8:00am to 5:00pm.

The principal dentist is registered with the Care Quality Commission (CQC) as an individual provider. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is run.

The inspection took place over one day and was carried out by a CQC inspector and a dental specialist advisor.

Before the inspection we sent CQC comments cards to the practice for patients to complete to tell us about their experience of the practice. Five patients provided feedback about the service. Patients were positive about the care they received from the practice. They commented that treatments were explained fully and staff were polite and courteous.

Our key findings were:

• Patients’ needs were assessed and care was planned in line with current guidance such as from the National Institute for Health and Care Excellence (NICE).
• The practice appeared clean and tidy and free from clutter
• There were effective systems in place to reduce and minimise the risk and spread of infection with the exception of an infection prevention and control audit which had not been completed.
• The practice had effective safeguarding processes in place and staff understood their responsibilities for safeguarding adults and children living in vulnerable circumstances Not all staff had completed the formal training.
• Equipment, such as the air compressor, autoclave (steriliser), fire extinguishers, and X-ray equipment had all been checked for effectiveness and had been regularly serviced.
• Patients indicated they felt they were listened to and that they received good care from a helpful and caring practice team.
• The staff told us they were well supported by the provider and felt listened to if they raised any concerns.
• Governance arrangements and audits were not always effective in improving the quality and safety of the services.

We identified regulations that were not being met and the provider must:

• Ensure there are robust processes for reporting, recording, acting upon and monitoring incidents and significant events and learning points are documented and shared with all relevant staff.
• Ensure that all practice risk assessments are updated and accurately reflect potential hazards to both patients and staff and comply with the Control of Substances Hazardous to Health 2002 (COSHH) regulations.
• Ensure the practice undertakes a Legionella risk assessment and implements the required actions giving due regard to guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’
• Ensure the practice’s sharps handling procedures and protocols are in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
• Ensure audits of various aspects of the service, such as radiography and infection control are undertaken at regular intervals to help improve the quality of service.

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

• Review the practice's protocols for completion of dental care records taking into account guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping. Review stocks of medicines and equipment and the system for identifying and disposing of out-of-date stock.
• Review the protocols and procedures for use of X-ray equipment taking into account Guidance Notes for Dental Practitioners on the Safe Use of X-ray Equipment.

During our inspection we spoke with the provider, three members of staff and four people who used the service. Six people completed a questionnaire for us. We observed two treatment sessions and looked at five patient records.

People who used the service told us that staff always treated them with respect. One person told us, “Me and my family are always treated with respect by staff.”

They told us they were involved in discussions about their treatment. They told us they received a treatment plan with the cost of the treatment.

People told us that they always felt safe when they received treatment at the practice. They told us that staff were very polite.

People we spoke with told us that the treatment rooms and waiting area were always very clean and tidy and all staff wore personal protective clothing.

People told us they had never had the need to make a complaint but they knew how to make a one.

We found the service was compliant with the five outcomes we looked at.