We undertook a follow up focused inspection of Church Lane Dental Practice on 12 November 2018. 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.

We undertook a comprehensive inspection of Church Lane Dental Practice on 7 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 in accordance with the relevant regulations 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 Church Lane Dental Practice 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?

Our findings were:

Are services well-led?

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

The provider had made improvements in relation to the regulatory breach we found at our inspection on 7 June 2018.

Background

Church Lane Dental Practice is in Harpurhey and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. On street parking is available near the practice.

The dental team includes five dentists, seven dental nurses (one of which is a trainee), a dental hygiene therapist and a practice manager. 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.

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

Monday to Thursday 9:30am to 1pm and 2pm to 5:30pm

Friday 9.30am to 3pm

Our key findings were:

• The practice had systems to identify and manage risk effectively. Improvements had been made in relation to hazardous substances, Legionella and fire safety.
• Emergency equipment and medicines were available as described in recognised guidance.
• The practice had improved safeguarding training processes.
• Staff files had been reviewed and now contained all the required evidence, including DBS checks and immunity.
• The safety and use of radiography had been reviewed.
• The system to audit radiography and infection prevention and control had been improved.
• Infection prevention and control procedures had been reviewed and improvements made in line with The Health Technical Memorandum 01-05: Decontamination in primary care dental practices
• The practice had signed up to, and funded access to an online training provider for all staff.
• The practice was engaging with the locality Oral Health Promotion Unit and participating in local oral health improvement projects.

We carried out this announced inspection on 7 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 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

Church Lane Dental Practice is in Harpurhey and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. On street parking is available near the practice.

The dental team includes five dentists, seven dental nurses (one of which is a trainee), a dental hygiene therapist and a practice manager. 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.

On the day of inspection we collected 58 CQC comment cards filled in by patients.

During the inspection we spoke with three dentists, dental nurses, 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 to Thursday 9:30am to 1pm and 2pm to 5:30pm

Friday 9.30am to 3pm

Our key findings were:

• The practice was renovated to a high standard and appeared clean and well maintained.
• Improvements were needed to the infection control procedures.
• Staff knew how to deal with emergencies. Improvements were needed to the medicines and life-saving equipment available.
• The practice staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
• The practice had staff recruitment procedures. References and DBS checks were not sought.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• The practice was part of a pilot contract; they provided preventive care and supporting patients to ensure better oral health.
• The appointment system met patients’ needs.
• The practice had effective leadership and culture of continuous improvement.
• Staff felt involved and supported and worked well as a team.
• The practice asked staff and patients for feedback about the services they provided.
• The practice staff dealt with complaints positively and efficiently.
• The practice staff had suitable information governance arrangements.

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.

Full details of the regulation the provider is not meeting are at the end of this report.

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

• Review the practice’s protocols for domiciliary visits taking into account the 2009 guidelines published by British Society for Disability and Oral Health in the document “Guidelines for the Delivery of a Domiciliary Oral Healthcare Service”.

• Review the security of NHS prescription pads in the practice and ensure there are systems in place to track and monitor their use.

• Review the availability of an interpreter service for patients who do not speak English as their first language.

• Review staff awareness of the requirements of the Mental Capacity Act 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.

We observed that all areas were clean. There was a reception and waiting area both upstairs and downstairs in which we saw a range of posters and information. Some promoted oral hygiene whilst others offered information about the practice, safeguarding and how to make complaints.

We observed that patients were given a pleasant welcome and spoken to with politeness and respect by the various receptionists. Patient’s details were confirmed on arrival. We heard staff offer staff a range of times and dates for follow up appointments.

We spoke with 8 patients during the inspection. Comments included: "Last time [the dentist] explained everything whilst doing it, it made me feel so much better.” “I always know what treatment is needed” and “There is plenty of information in here and downstairs”.

We looked at records, which were a combination of paper and electronic records. We found they were factual and up to date. We saw patients' medical history; treatment plans and personal preferences were regularly reviewed and updated.

We saw that policies and procedures were accessible to staff in the main staff area along with emergency medical equipment which was all in date.

Decontamination processes were seen to be followed and hygiene procedures were adhered to by staff, to minimise the risk of cross infection.

We observed that comments and feedback was taken seriously by the practice and used to inform changes and improvements to the service delivered.