We carried out an unannounced comprehensive inspection on 26 October 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 not 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

Brighton White Dental Studio provides predominately NHS dental services with private treatment options for patients. The practice has four consulting and treatment rooms; one of which was not in use. The practice has four dentists who are supported by three registered dental nurses and two student nurses. The practice also has two hygienists. The practice is managed by a practice manager, who is responsible for two practices in the group with oversight from the principal dentist who is also the provider.

The provider 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.

We spoke with five patients following our inspection who told us that they were satisfied with the services they had received. All stated their experiences at the practice were mostly good, that staff were kind and caring. However, appointments were not always available, both for emergencies and routine visits and often incurred a long wait. They spoke about how their dignity and privacy was maintained at all times and how they were involved in decisions regarding their care and treatment. We did not provide any comment cards prior to our inspection as this was unannounced.

We found this practice was not providing safe care in accordance with the relevant regulations and identified regulations were not being met. We asked specific questions regarding sedation at the practice and following our inspection the practice has declared that they will no longer provide sedation to patients.

Our key findings were:

• Patients’ needs were assessed and care was planned and delivered in line with current practice guidance from the National Institute for Health and Care Excellence (NICE) and other published guidance.
• The practice did not have systems and processes to record, investigate, respond to and learn from significant events or knowledge of what a significant event was.
• The practice had not carried out effective audits in key areas, such as infection control, sedation and the quality of X-rays.
• The practice had safeguarding processes and staff understood their responsibilities for safeguarding adults and children living in vulnerable circumstances.
• The practice had not conducted risk assessments in relation to radiography, sedation, the safe use of sharps or fire safety.
• Environmental cleaning was not effective.
• The practice had not been maintained to a sufficient standard
• There were no operational policies for staff to refer to in the practice as these were kept offsite.
• Policies we received following our inspection, did not have up to date information, did not reflect current practice and processes and were not dated.

• Recruitment processes were not sufficient and staff files lacked some required documentation.
• The practice did not hold regular staff meetings and formal staff appraisals, and the appraisals undertaken had not identified training needs.

• Staff had received some training appropriate to their roles and were supported in their continued professional development (CPD).
• The practice did not handle complaints effectively or used these to help them improve the practice.
• Radiological practices were not carried out in line with current legislation.
• Patients told us they often experienced a delay in obtaining an appointment.
• Patients were pleased with the care and treatment they received and complimentary about the dentists and other members of the practice team.
• Clinical governance activity was not sufficient, audits we reviewed did not reflect processes in the practice, therefore no learning or improvements could be made.
• The practice had not registered with the Information Commissioners Office that they were using CCTV on the premises.

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

• Ensure that staff understand what constitutes a significant event, and establish systems and processes to investigate, respond to and learn from significant events.
• Ensure that appropriate governance arrangements are implemented for the safe running of the service by establishing systems to identify and minimise any potential or perceived risks.
• Ensure that the practice is compliant with its legal requirements under Ionising Radiation Regulations (IRR99) and the Ionising Radiation (Medical Exposure) regulations (IR(ME)R) 2000
• Ensure procedures are in place to assess the risks in relation to the Control of Substances Hazardous to Health (COSHH) 2002 Regulations.
• Ensure audits of various aspects of the service, such as radiography, infection control, and dental care records are undertaken at regular intervals to help improve the quality of service. Practice should also ensure all audits have documented learning points and the resulting improvements can be demonstrated.
• Ensure the practice's recruitment policy and procedures are suitable and the recruitment arrangements are in line with current legislation.
• Ensure that equipment used for sterilisation and X-rays are regularly maintained.
• Ensure that single use items such as matrix bands are only used for one patient and then disposed of.

We carried out this announced responsive inspection on 21 June 2017 to follow up on our previous inspection on 26 October 2016 where we found breaches of regulations 12 and 17. This inspection was carried out 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 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 well-led?

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

Background

Brighton White Dental Studio is in Brighton and provides NHS and private treatment to patients of all ages.

There is access via a small flight of stairs and the practice has a portable ramp for people who use wheelchairs and pushchairs. Car parking spaces, including those for patients with disabled badges, are available near the practice.

The dental team includes four dentists, three registered dental nurses, two student dental nurses, two dental hygienists, a practice manager who manager’s two locations owned by the principal dentist and a receptionist. The practice has three 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.

We did not provide comment cards on this occasion as the inspection focused on the previous breaches of regulations 12 Safe care and 17 Good governance.

During the inspection we spoke with two dentists, two dental nurses, the receptionist 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- Thursday 9am -6pm

Friday 9am -5pm

Our key findings were:

• The practice had a system to record, analyse and learn from significant events, accidents and incidents.
• The practice had infection control procedures which reflected published guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
• The practice had systems to help them manage risk.
• The practice had up to date policies and procedures for staff to refer to.
• Radiological practices were now carried out in line with current legislation
• The practice had completed audits for radiographical image quality and infection control
• Recruitment practices had been improved and all of the required documentation was available.
• The practice held regular staff meetings.
• Staff had completed the required training.

At the last inspection in July 2013 we found Brighton White Dental Studio non-compliant with regulations 12 and 16 of the Health and Social Care Act (HSCA) 2008. This was because the provider had failed to have effective systems to manage the risk of infection and had not made suitable arrangements to protect patients and staff from the risks associated with unsafe equipment. At this inspection we found that the provider had taken the steps they needed to achieve compliance.

We spoke with the provider and a dental nurse. We were not able to speak with patients as none were scheduled during our inspection. We observed decontamination cycles and other processes were demonstrated to us. We looked at other documents to confirm what we were told and observed.

We found that government guidance for decontamination and the control of infection were being followed. Staff had undertaken further training in this area. A dental nurse said, “We’ve gone over quite a lot; things we weren’t sure of. We’ve made sure everyone is fully aware of what to do and we’ve practised and practised. Everyone is really up to date.”

The former staff room had undergone changes to significantly reduce risks to staff and patients and an x-ray machine had been decommissioned due to safety concerns. Faculty of General Dental Practitioner guidelines were now being followed in relation to monitoring the quality of x-rays.

We spoke with two dentists, one of whom was the provider, the practice manager, two trainee dental nurses (called dental nurses in this report) and a receptionist. We also spoke with five patients.

Patients were supported to give informed consent before treatment. A patient said, “The difference between NHS and private costs has always been explained. I am never forced to have treatments. I am always offered the teeth whitening service but as soon as I say that I don’t want it that is the end of it. The dentist gives me options and I make the decision about what treatments to have.”

Patients’ care was planned to meet their needs. A patient said, “I think they are an excellent dentist. Very kind.” Another commented, “The care here is good. Very professional. They don’t do more than they need to.”

Staff told us they were supported; a dental nurse said, “I feel really comfortable asking any member of staff. [The provider] and [the manager] are approachable and I feel supported.” Staff received further training to maintain and enhance their skills.

There were systems to gather feedback from patients and their suggestions were acted on. The manager said, “I treat complaints like a patient survey; it’s important what people say to us.”

We found some equipment was poorly sited and presented risks to patients and staff.

We found that not all government guidance in relation to the decontamination of dental equipment and infection control was being followed.