We carried out this announced inspection on 24 April 2017 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.

We told the NHS England area team and Healthwatch that we were inspecting the practice. They did not provide any information.

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

Background

The practice is in the city centre of Exeter in Devon and provides NHS treatment to patients of all ages.

There are steps to the practice from the street and all surgeries are accessed via stairs. There is a public car park nearby.

The dental team includes four dentists, three dental nurses, three trainee dental nurses, one dental hygienist and three receptionists. There is a practice manager, who is also a qualified dental nurse. The practice has five 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 Clock Tower Dental Practice was the practice manager.

On the day of inspection we collected 19 CQC comment cards filled in by patients and spoke with two other patients. This information gave us a positive view of the practice.

During the inspection we spoke with three dentists, two dental nurses, one trainee dental nurse, two receptionists, the practice manager and the company area compliance officer. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open: Monday to Thursday 8am – 7pm. Friday 8.30am – 5pm. Saturdays 9am – 1pm.

Our key findings were:

• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
• The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children. .
• 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 appointment system met patients’ needs.
• The practice had effective leadership. 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 dealt with complaints positively and efficiently.
• Improvements could be made with regard to the practice’s staff recruitment procedures.
• The practice had systems to help them manage risk but improvements could be made.

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

• Review the practice’s infection control procedures and protocols including undertaking a Legionella risk assessment and implementing the required actions taking into account guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and giving due regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’.
• Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.

Our findings were:

Are services safe?

We found this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

This was not checked at this inspection.

Are services caring?

This was not checked at this inspection.

Are services responsive?

This was not checked at this inspection.

Are services well-led?

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

We carried out an inspection of this service under Section 60 of the Health and Social Care Act 2008 on 15 January 2015 as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to look at the overall quality of the service. Breaches of legal requirements were found. As a result we undertook a desk based focused inspection on 20 February 2016 to follow up on whether action had been taken to deal with the breaches.

During our previous inspection on the 15 January 2015 we found the following:

• An effective system was not in place to carry out clinical governance and audits. Actions highlighted from audits had not been taken in a timely way. This included shared learning from significant events.
• X-ray audits had not been carried out at the practice as required by the IR(ME)R 2000 regulations.
• The practice did not have a radiation protection file which included details of the Radiation Protection Supervisor (RPS) and the new appointment of the Radiation Protection Advisor (RPA).
• Infection control audits had not addressed any shortfalls as determined by the ‘Health Technical Memorandum 01-05: Decontamination in primary care dental practices’ (HTM 01-05). This includes the processes and practices which are essential to prevent the transmission of infections.
• The practice had not carried out or logged the recommended procedures contained in the Legionella risk assessment.
• Action had not been taken in response to the fire risk assessment, such as confirming which doors were fire doors.
• Patient records had not been stored securely or retained for an appropriate amount of time.

We conducted a desk based focused inspection. This means the provider was able to send us evidence of the action taken to address the issues previously found rather than visiting the practice. The provider had actively demonstrated that they had taken action in response to the areas of non-compliance which were identified at the previous inspection on 15 January 2015.

During this desk based inspection we found:

• An effective system was in place to carry out clinical governance and audits. Significant events were being discussed at staff meetings including any learning and improvements which had taken place as a result of these.
• X-ray audits had recently been carried out by all dentists at the practice as required by the IR(ME)R 2000 regulations.
• The practice had a radiation protection file in place which included details of the Radiation Protection Supervisor (RPS) and the new appointment of the Radiation Protection Advisor (RPA).
• Work had been completed in order to address shortfalls as a result of infection control audits as determined by HTM 01-05 guidance.
• A recent Legionella risk assessment had been carried out and any actions which needed to be taken were clearly highlighted.
• Action had been taken in response to the fire risk assessment, including the clear marking of fire doors throughout the practice.
• Patients’ dental care records were being stored and archived securely.

We carried out a comprehensive inspection of the Clock Tower Dental Practice on 15 January 2015.

Clock Tower Dental Practice is run by Den Dental Group Practices LLP. In October 2014 it was acquired by a large dental corporate body, Oasis Dental Care.

The Clock Tower Dental Practice, Exeter provides general dentistry under an NHS contract. Patients have the option of private treatments if they choose. This practice is in Exeter city centre and treats patients of all ages and diverse backgrounds. It is not accessible for patients who require wheelchair access. There are no treatment rooms on the ground floor, three are on the first floor and one on the top floor.

The practice opens from 8.30am to 5pm Monday to Friday, closing for lunch between 1 and 2pm. Five dentists and a dental hygienist worked at the practice.

We spoke with three patients during our visit. Feedback was provided by 18 patients who completed our comment cards. Patients told us they were very happy with the treatment they received at this practice. Typical comments included tributes to the thorough and appropriate treatments patients had received and the helpfulness and friendliness of staff. Several patients commented that they had not been kept waiting long for their appointment. Patients said their concerns about their teeth had been addressed and additional information had been provided to help them with self-care. One person told us they had contacted the service early that morning requesting urgent treatment and had their appointment at 10am. They were very pleased with the service.

Before this inspection we noted on NHS Choices website several patients had recorded their dissatisfaction with the length of time it took them to get through to the practice by telephone, being kept waiting on the line accruing charges.

Our key findings were:

• Patients were happy with the service they received. They were given good information on which to base decisions about their treatment. They were pleased with their treatment and advice given about how to care for their teeth.
• Patients were treated with respect by friendly caring dentists and staff.
• Some patients found that it took a long time to get through to the practice by phone. However, once connected, they could get appointments at times that suited them.
• The registered manager ensured that all relevant training was attended and completed so that dentists and staff were working within their sphere of competency. There were practice meeting records showing regular 'in house' training covering a wide variety of topics.

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

• introduce a system of management that ensures audits are carried out and action taken in a timely way.

• carry out a regular audit of all X-rays taken in the practice as required by the IR(ME)R 2000 regulations.
• create and maintain a current and relevant radiation protection file which includes updated local rules showing the current Radiation Protection Supervisor (RPS) and the new appointment of the Radiation Protection Advisor (RPA).
• carry out audits of the infection control processes in the practice, to identify and address any shortfalls as determined by HTM 01-05. This includes the facilities provided for decontaminating instruments used in dentistry, storage of instruments and materials in the surgeries to protect them from contamination, and safe transportation of instruments coming from another practice for decontamination.
• ensure that the recommended procedures contained in the Legionella risk assessment are being carried out and logged appropriately.
• take action in response to the fire risk assessment.
• store patient records securely and retain them for an appropriate period of time.

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

There were areas where the provider should make improvements:

The provider should

• carry out an assessment of the premises in accordance with the Disability Discrimination Act 2005.

There were five dentists working at Clock Tower Dental Practice at the time of our inspection, two part-time. We spoke with the practice manager (also the lead nurse for infection control), a dentist, receptionists and two dental nurses. We spoke with six people who had been asked for permission to speak with us about their experiences.

One person told us they were “very satisfied with the service and pleased with our check ups, which were thorough”. Another person said “We were impressed with the quality of treatment and care provided by the dentist. An excellent service”. Praise for the service, especially for children, was also given.

People told us that the dentists gave them good information and they got appointments on dates of their choice, including emergency appointments. One person said, “The reception staff were very welcoming and informative in assisting us with our visit”. Patients were able to comment on the NHS website. A recent comment stated that it was a “Brilliant experience, with friendly staff and competent dentists”. Any negative comments had been responded to in a comprehensive way and solutions offered.

We saw that new patients were asked for their medical history each visit, so that the dentist would know of any necessary precautions and staff were well trained.

The practice had good processes to keep people safe but measures for reporting safeguarding adult alerts were not as robust as they could be.

People who used the service told us they were happy with the treatment provided at Clock Tower Dental Practice. They said that staff were polite and helpful. One person said “Staff are friendly and polite here”. This was confirmed from our observations during our inspection visit.

People told us they had seen a number of different dentists over the last year or so. They said this made them feel more anxious because they could not guarantee they would see the same dentist. We spoke with the practice manager about this, who said that there had been a variety of reasons why there had been so many changes but the majority of dentists had been working at the practice for over a year.

People also told us they were able to make routine appointments easily. They said that if they required an emergency appointment, the practice usually arranged this within 48 hours of their request.

People we spoke with told us they were always asked for an updated medical history on each visit to the practice. We looked at the dental records of five people. They showed confirmation of what people told us. This would ensure any treatment provided by the practice would not compromise any other treatment they received.