We carried out a follow- up, desk based inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions at Cadis Practice Limited on the 8 August 2017.

We had undertaken an unannounced comprehensive inspection of this service on the 6 March 2017 as part of our regulatory functions where a breach of legal requirements was found.

After the comprehensive inspection, the practice manager wrote to us to say what they would do to meet the legal requirements in relation to the breaches. This report only covers our findings in relation to those requirements.

We reviewed the practice against two of the five questions we ask about services: is the service safe and is the service well led? You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Cadis Practice Limited on our website at www.cqc.org.uk.

Our findings were:

Are services safe?

We found that this practice was now providing safe care in accordance with the relevant regulations. The improvements needed had been made.

Are services well-led?

We found that this practice was now providing well-led care in accordance with the relevant regulations. The improvements needed had been made.

Background

Cadis Practice Limited is located in South Shore, Blackpool and provides private treatment to adults and children. The services includes preventative advice and treatment routine restorative dental care, dental implants and both inhalation and intravenous sedation. It is also known as the Cosmetic and Dental Implant Surgery.

Wheelchair users or pushchairs can access the practice by alerting the staff via a low level bell and using a portable ramp at the front of the practice. Car parking spaces are available outside the practice.

The dental team is comprised of the principal dentist, a dental nurse who also acts as the practice manager, one trainee dental nurses (one of which is a trainee), a dental hygienist and a receptionist.

The practice has two ground floor surgeries, a dedicated room for taking orthopantomogram (OPG) X-rays, a decontamination room, a staff room/kitchen and a general office.

The practice is open:

Monday 9am - 6pm

Tuesday 9am - 1pm

Friday 9am – 5pm

Our key findings were:

• The practice had completed an infection control audit using a recognised audit tool and a radiograph audit.
• All missing emergency medical equipment had been purchased.
• Staff recruitment procedures have been review and necessary employment checks had been undertaken.
• Dates for staff appraisals had been identified. Training needs will be identified at appraisal. Training was now monitored by the practice manager.
• The practice had addressed the actions identified in their Legionella risk assessment.
• Safety Data Sheets had been obtained, and risk assessments undertaken, for all COSHH products used in the practice.
• Policies and procedures for the safeguarding of children and adults, infection prevention and control and the reporting of incidents and accidents had been updated.
• Fire safety checks were recorded
• Decontamination processes were validated and results recorded.

We carried out an unannounced comprehensive inspection on 6 March 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 that this practice was not providing safe care in accordance with the relevant regulations. The impact of our concerns, in terms of the safety of clinical care, is minor for patients using the service. Once the shortcomings have been put right the likelihood of them occurring in the future is low.

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

Cadis Practice Limited is located in South Shore, Blackpool and provides private treatment to adults and children. The services includes preventative advice and treatment routine restorative dental care, dental implants and both inhalation and intravenous sedation. It is also known as the Cosmetic and Dental Implant Surgery.

Wheelchair users or pushchairs can access the practice by alerting the staff via a low level bell and using a portable ramp at the front of the practice. Car parking spaces are available outside the practice.

The dental team is comprised of the principal dentist, two dental nurses (one of which is a trainee), a dental hygienist and a receptionist.

The practice has two ground floor surgeries, a dedicated room for taking Orthopantomogram (OPG) X-rays, a decontamination room, a staff room/kitchen and a general office.

The practice is open:

Monday 9am - 6pm

Tuesday 9am - 1pm

Friday 9am – 5pm

The dentist shares their time between this practice and the sister practice in Kendal.

The reception is open when there is no dentist available. When the practice is closed all phone calls are diverted to the Kendal practice and emergency appointments would be made at the practice which suits the patient.

The Principal dentist 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.

Our key findings were:

• The practice appeared clean and well maintained.
• Infection control procedures were robust and the practice followed published guidance.
• There were sufficient numbers of suitably qualified staff to meet the needs of patients.
• Treatment was well planned and provided in line with current guidelines.
• Patients were treated with dignity and respect and confidentiality was maintained.
• The appointment system met patients’ needs.
• The service was aware of the needs of the local population and took these into account in how the practice was run
• The staff felt involved and supported and worked well as a team.

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

• 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 knows about their responsibilities in regards to Control of Substance Hazardous to Health (COSHH) Regulations 2002 and ensure all documentation is up to date and staff understand how to minimise risks associated with the use of and handling of these substances.
• Ensure the practice has arrangements in place for the receiving and responding to patient safety alerts, recalls and rapid response reports issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and through the Central Alerting System (CAS), as well as from other relevant bodies such as, Public Health England (PHE).
• Ensure that the practice policies, including safeguarding adults and children, infection prevention and control and Health and Safety, are reviewed to bring them in line with local policy and procedures.
• Ensure that the practice has protocol in place for reporting significant events and reporting incidents, accidents and Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR) and reporting notifications to the CQC.
• Ensure the practice’s sharps handling procedures and protocols are in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
• Ensure the training, learning and development needs of staff members are reviewed at appropriate intervals and an effective process is established for the monitoring of staff training.
• Ensure that the required audits for X-rays are completed.
• Ensure the infection prevention and control audit is effective in highlighting all of the potential risks to service users.
• Ensure a process is in place to ensure staff ‘s Hepatitis B immunity is up to date

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 practice has availability equipment to manage medical emergencies giving due regard to guidelines issued by the British National Formulary, the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.
• Review that the practice has an effective fire risk management and safety check system.
• Review the audit process and complete an action plan to ensure learning and improvement can be made.
• Review the practice data protection and information governance policies are in line with the Information Commissioning Office (ICO) recommendations. Ensure the practice registers with the ICO. Ensure that staff are trained in information governance.
• Review the validation procedures of all decontamination processes and implement logs to record the process.
• Review the practice's recruitment policy and procedures are suitable and the recruitment arrangements are in line with Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 to ensure necessary employment checks are in place for all staff and the required specified information in respect of persons employed by the practice is held. Ensure induction training and awareness of practice policies is implemented.