We carried out this announced inspection on 8 August 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions.

Blackbrook Dental Practice received a comprehensive inspection on 31 January 2017 and we served a requirement notice for regulation 17 good governance. They required improvement in ensuring the service was assessed and monitored to ensure risks were mitigated and they improved the quality and safety of services provided. This included the taking actions following risk assessments carried out for health and safety and fire safety. They also had some areas where they should improve and we reviewed these areas. This included having an annual infection control statement in place.

The inspection was led by a CQC inspector who had access to a remote 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. During this inspection we reviewed the relevant parts of the well-led key question to check if they were now meeting our standards.

Our findings were:

Are services well-led?

We found that this practice was providing well-led care in accordance with the relevant regulations.

Background

Blackbrook Dental Practice is in Taunton and provides NHS and private treatment to patients of all ages.

There is level access for patients who use wheelchairs and pushchairs. Car parking spaces, including two for patients with disabled badges, are available near the practice.

The dental team includes five dentists, one dental hygienist, one qualified dental nurse and six trainee dental nurses. The trainee dental nurse job role also includes reception cover. The practice has four treatment rooms.

The practice is owned by a company and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers 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 registered manager at Blackbrook Dental Practice was the practice manager.

During the inspection we spoke with the practice manager and looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

• Monday, Wednesday and Thursday - 8:15am to 5:15pm
• Tuesday - 8:15am to 7pm
• Friday - 8:15am to 4:15pm

Our key findings were:

• The practice had taken action and addressed issues identified within risk assessments to ensure risks were mitigated. This included fire safety, health and safety and legionella.
• There were processes in place to ensure infection control procedures were met including the completion of an annual infection control statement.
• Daily checks were recorded to show unpackaged instruments were reprocessed at the end of the working day.
• The practice had effective leadership. The manager had made changes to ensure staff felt involved and supported and worked well as a team.

We carried out an announced comprehensive inspection on 31 January 2017 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 this practice was providing safe care in accordance with the relevant regulations.

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

Blackbrook Dental Practice is situated in a modern purpose built building in a residential area and close to bus routes. The practice provides NHS general and restorative dental services to children and adults and some private patients.

The facilities include four surgeries and a purpose built, dedicated decontamination/ sterilisation room plus spacious waiting areas. The facilities are fully equipped to cater for people of all ages and abilities. Children are made welcome. The practice has wheel chair access to the three ground floor surgeries. There is a hearing loop at reception and information materials can be provided in large font. Access to translation services is available on request.

Fees for both NHS and private were displayed in information leaflets for patients available in the practice and on the practice website. There are arrangements in place to ensure patients receive urgent dental assistance when the practice is closed. This is provided by an out-of-hours service which can be accessed by calling NHS 111. These arrangements were displayed in the practice and on a telephone answering service.

At the time of the inspection the practice did not have a registered manager in post. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. 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 practice is open Monday, Wednesday and Thursday 8.15am to 5.15pm, Tuesday 8.15am to 7.00pm, Friday 8.15am to 4.15pm. The service is closed at weekends but offers an Out of Hours service via the local NHS community dental services.

We reviewed 10 CQC comment cards that had been left for patients to complete prior to our visit. In addition we spoke with six patients on the day of our inspection.

Feedback from patients was positive about the care they received from the practice. They commented the staff put them at ease and listened to their concerns. They also reported they felt proposed treatments were fully explained them so they could make an informed decision which gave them confidence in the care provided. Patients we spoke with and the comment cards told us staff were kind, caring, competent and put patients at their ease. Three patients spoke of the fast turnover of staff especially at reception.

Our key findings were:

• There were systems in place to help ensure the safety of staff and patients but some were not operated effectively. These included safeguarding children and adults from abuse, maintaining the required standards of infection prevention and control and responding to medical emergencies.
• We observed and were told by staff the practice ethos provided patient centred dental care in a relaxed and friendly environment.
• Leadership had been lacking until two weeks prior to the inspection when a new practice manger had commenced in post.
• Staff had been trained to handle emergencies and appropriate medicines and life-saving equipment were readily available in accordance with current guidelines.
• The dental practice did not have effectively operated clinical governance and risk management processes in place for health and safety.
• Patient care and treatment was delivered in line with evidence-based guidelines, best practice and current legislation including National Institute for Care Excellence (NICE) guidelines.
• Patient dental care records were electronic, detailed and comprehensive.
• The practice had a system to monitor and improve the quality of the service; including through a detailed programme of clinical and non-clinical audits.
• The use of digital radiographs to help explain necessary treatment to patients while in the chair.
• Premises appeared well maintained and visibly clean. Good cleaning and infection control systems were mostly in place. The treatment rooms were well organised and equipped, with good light and ventilation.

• There were systems in place to check all equipment had been serviced regularly, including the air compressor, autoclave, fire extinguishers, oxygen cylinder and the X-ray equipment.
• There were sufficient numbers of suitably qualified staff who maintained the necessary skills and competence to support the needs of patients.
• Staff were up to date with current guidelines, supported in their professional development and the practice was led by a proactive principal dentist.
• The service was aware of the needs of the local population and took these into account in how the practice was run.
• Patients could access treatment and urgent and emergency care when required with information for out of Hours service clearly available.
• Staff received training appropriate to their roles and were supported in their continuing professional development (CPD) by the company.
• Staff we spoke with were committed to providing a quality service to their patients but had not felt well support until the very recent arrival of the new manager.

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

• Ensure an effective system is established to assess, monitor and mitigate the various risks arising from undertaking of the regulated activities including fire and health and safety.

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

• Review the practice infection control procedures and protocols 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 with particular attention to the Annual Infection Control statement.

We carried out an announced comprehensive inspection on 28 July 2015 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 this practice was not providing safe care in accordance with the relevant regulations and requires improvement.

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 providing well-led care in accordance with the relevant regulations.

Background

CQC inspected the practice on 19 November 2014 and asked the provider to make improvements regarding legal requirements relating to cleanliness; infection control and monitoring the quality of the service provided. We checked these areas as part of this comprehensive inspection and found they had mostly been resolved.

The practice offers mainly NHS treatment and some private treatment services for its patient population. Blackbrook Dental Surgery has four dentists one of whom offers an orthodontic (tooth alignment) service. There is a practice manager, one dental hygienist, five trainee dental nurses and two receptionists. At the time of our inspection there were four dentists supported by trainee dental nurses on duty to meet the demands of the patient population. The practice manager was also in attendance.

The practice manager is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. 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 practice is open Monday, Wednesday and Thursday 8.15am to 5.15pm, Tuesday 8.15am to 7.00pm, Friday 8.15am to 4.15pm. The service is closed at weekends but offers an Out of Hours service via the local NHS community dental services.

We spoke with eight patients who used the service on the day of our inspection and reviewed 20 Care Quality Commission (CQC) comment cards that had been completed by patients prior to the inspection. The patients we spoke with were very complimentary about the service. They told us they found the staff to be extremely friendly and welcoming and felt they were treated with dignity and respect. The comments on the CQC comment cards were also very complimentary about the staff and the service provided.

We found the practice was effective in treatments provided, caring and responsive to patients needs and well led by the practice manager. We found the provider and manager had taken action to address the areas of non-compliance found at the last inspection.

We found the practice had not carried out appropriate checks on staff for example a Disclosure and Barring check (DBS) prior to their employment at the practice. A DBS check identifies whether a person has a criminal record or is on an official list of persons barred from working in roles where they will have contact with children or adults who may be vulnerable. All the dental nurses employed at the practice are trainee nurses who do not have the relevant training skills and knowledge of registered dental nurses. However some trainees are undertaking a dental nurse apprenticeship course with a local provider.

Our key findings were:

• Patients’ needs were assessed and care was planned in line with best practice guidance such as that from the National Institute for Health and Care Excellence (NICE). NICE is the organisation responsible for promoting clinical excellence and cost-effectiveness and producing and issuing clinical guidelines to ensure every NHS patient gets fair access to quality treatment.

• There were effective systems in place to reduce and minimise the risk and spread of infection.

• 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.

• The practice had effective safeguarding processes in place and staff understood their responsibilities for safeguarding adults living in vulnerable circumstances and children.

• Staff reported incidents and kept records of these which the practice used for shared learning.

• The patients we spoke with and all the comment cards we reviewed indicated patients were consistently treated with kindness and respect by staff. It was reported communication with patients and their families, access to the service and to the dentists, was good. Patients reported good access to the practice with emergency appointments available the same day.

• The practice had implemented clear procedures for managing comments, concerns or complaints.

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

• Ensure records of identification checks are included in staff personnel files and use current DBS checks. Ensure risk assessments are in place to assess the need for criminal record checks for non-clinical staff or those for whom no completed DBS check has been received.

• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the needs of patients using the service; by reviewing the skill mix of trained and trainee dental nurses in the practice for the safety and protection of patients.

You can see full details of the regulations not being met at the end of this report.

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

• Review the management of prescriptions issued to ensure an audit trail is available for all prescriptions issued.

• Review corporate leadership and management involvement and support to the practice; to ensure good leadership and an open, transparent culture between the location and the provider.

We carried out this inspection on 19 November 2014 in response to information of concern we had received. The information of concern related to the care and welfare of patients and the cleanliness and infection control processes at the practice.

On the day of our visit we spoke with four patients who were complimentary about the practice. All felt they were treated with respect and dignity. We observed verbal consent to treatment was obtained prior to treatment thus respecting patient's wishes. All four patients told us they were informed about the treatment alternatives and possible outcomes of the treatment.

We saw a patient satisfaction survey was used to gather feedback. Patients we spoke with told us they could make an appointment at times that suited them. They told us they were aware of the emergency number and could usually get an appointment within 24 hours.

The practice had access for people with disabilities including wheelchair users. Once in the practice there were facilities on the ground floor to provide all the services offered by the practice.

We observed the decontamination processes and storage of instruments and saw there was a risk of acquiring a healthcare associated infection because the practice did not have effective systems in place to prevent and control infections.

We found the systems in place to monitor and improve the quality of the service provided were ineffective. We also found the registered manager was no longer working at this location but had not cancelled their registration. The current manager had not applied to be registered with CQC for this service.

During our inspection we spoke with ten people who used the service. They were all happy with the service provided by the dental team. One person said “the service is good, I would say otherwise”. We asked if the service could be improved and were told “I wouldn’t say so, I’m pretty happy with the service I get”.

People told us they could express their views and were given appropriate support and information for their treatment choices. Dentists completed treatment records which showed why decisions were made for particular treatments, advice and options given.

We spoke with four out of the five dentists and four out of the seven dental nurses who were employed by the service. They told us they felt well supported and had a good knowledge of infection control and of their role in safeguarding children and vulnerable adults.

The practice manager and provider had good systems in place to monitor and assess the quality of the service.