We undertook this follow-up focused inspection on 28 February 2019. 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 Care Quality Commission (CQC) inspector who was supported by a specialist dental adviser.

We previously undertook a comprehensive inspection on 23 and 25 July 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 safe, effective or well led care and was in breach of Regulations 12, 17, 18 and 19 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 Confidental Care on our website www.cqc.org.uk.

As part of this inspection we asked:

• Is it safe?

• Is it effective?

• Is it well-led?

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 the service again after a reasonable interval, focusing on the areas where improvement was required.

Our findings during this inspection were:

Are services safe?

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

The provider had made several improvements in relation to the regulatory breach we found during the previous inspection on 23 and 25 July 2018.

Are services effective?

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

The provider had made improvements in relation to the regulatory breach we found at our inspection on 23 and 25 July 2018.

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 breaches we found at our inspection on 23 and 25 July 2018.

Background

Confidental Care is in the London Borough of Bromley and provides NHS and private treatment to patients of all ages.

The dental team includes three dentists, two qualified dental nurses (one of whom is a locum), a trainee dental nurse, three decontamination assistants (two of whom also undertake receptionist duties), and a receptionist. The provider had employed the services of a compliance adviser to assist them in implementing the necessary improvements.

The practice has five 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 two dentists, a compliance advisor, three dental nurses, a receptionist, and the practice administrator. We checked practice policies and procedures and other records about how the service is managed.

The practice is open at the following times:

Mondays to Thursdays – 9am to 6pm

Fridays – 9am to 5pm

Every other Saturday – 9am to 1pm

Our key findings were:

• The provider had established a system for identifying, receiving, recording, handling and responding to complaints by service users.
• The provider had implemented an effective system to ensure all referrals could be monitored suitably.
• Risks related to fire safety, electrical safety, health and safety, significant events, Legionella prevention, the security of prescription pads, infection prevention and control processes had been reviewed and mitigated.
• The provider had checked that clinical staff had achieved a satisfactory level of immunity against Hepatitis B.
• Prescription pads were stored securely.
• There was sufficient equipment used to manage medical emergencies, and these had been suitably maintained and monitored.
• The provider had improved arrangements for monitoring medicines and dental materials to ensure they remained in date and fit for use.
• The provider had implemented suitable up-to-date policies to provide guidance to staff.
• The provider had not carried out audits to monitor the quality of safety of the practice’s clinical systems and processes.
• The provider had made key safety improvements relating to the provision of dental treatment using conscious sedation. However, because the provider had not met all of the requirements of the conditions we had imposed upon their registration with the CQC in July 2018, we took the decision to continue the enforcement action to prevent them from providing dental treatments under conscious sedation until they have made the necessary improvements.
• The provider had improved their recruitment procedure to ensure key background checks were carried out for new staff, and they maintained up-to-date records relating to professional registrations and indemnity insurance for clinical staff.
• Staff had received appraisals, and they had completed key training and continuing professional development. The provider had implemented a system to monitor training needs of their staff.
• Staff reported that communication and morale had improved, and that there was more cohesive working amongst staff. They demonstrated a good understanding of governance arrangements and requirements.
• Dental care records were stored securely. Most dental care records were well-written but some lacked key information.
• Rubber dam was still not being used consistently or its non-use suitably risk assessed and documented by all dentists for root canal treatments.

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

• Review the practice's protocols for completion of dental care records, taking into account guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.
• Review the practice’s protocols for the use of rubber dam for root canal treatment taking into account guidelines issued by the British Endodontic Society.

People using the service told us they were happy with the dental care they received at the practice. One person told us that their dentist was “clinically thorough, professional and calm”. Two people told us that staff were polite and kind. People commented that the dental practice was clean when they visited and they had no complaints.

We saw that the dental practice was visibly clean and that staff wore personal protective equipment when delivering care and treatment. The provider had effective procedures in place for the decontamination of dental instruments and their storage. Medicines were safely managed to ensure that people using the service received safe care and treatment. Records relating to people’s care had been maintained, were stored securely and could be located promptly when requested.

People we spoke with told us that they were happy and satisfied with the service provided by the surgery. They told us that they had found the surgery to be clean whenever they visited. They said that staff kept them well informed, explained the procedures and provided clarification if it was needed.

They said that the staff were polite and friendly. One person said that they had been visiting the surgery for many years and never had any reason to complain.

We carried out this unannounced inspection on 23 and 25 July 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 Care Quality Commission (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 not providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this practice was not 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

Confidental Care is based in the London Borough of Bromley. The practice provides NHS and private treatment to patients of all ages.

The dental team includes three dentists, a practice manager, two qualified dental nurses, a trainee dental nurse and a receptionist. The practice has five treatment rooms, two of which were not in operation at the time of the inspection.

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 all the dentists, the practice manager, the qualified and trainee dental nurses and the receptionist. We checked practice policies and procedures and other records about how the service is managed.

The practice is open at the following times:

• Monday to Thursday: 9am to 6pm
• Friday: 9am to 5pm
• Every other Saturday: 9am to 1pm

Our key findings were:

• The appointment system met patients’ needs.
• The practice asked patients for feedback about the services they provided.
• The practice was providing preventive care and supporting patients to ensure better oral health.
• Staff felt supported, though not all felt involved, and not all felt there was a cohesive working culture.
• Not all staff knew how to deal with medical emergencies.
• Staff knew their responsibilities for safeguarding vulnerable adults and children, though staff were not clear on the designated safeguarding leads and external safeguarding contact details.
• The practice had complaints protocols but had not established an effective system to manage patient complaints.
• The practice did not follow current national guidance when undertaking dental treatment using conscious sedation.
• The practice had not adequately protected patients’ privacy and personal information.
• There was equipment to manage medical emergencies. We found some of this equipment had passed its use-by date.
• The practice had infection prevention and control procedures, though they did not reflect published guidance.
• The practice had not established thorough staff recruitment procedures.
• There was a lack of effective processes to ensure all staff had received or updated key training.
• The practice had not established effective systems to help them manage risks and there was a lack of effective systems and processes to ensure good governance.

We identified regulations the provider was not meeting. They must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

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

• Review the practice's protocols for completion of dental care records, taking into account guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.
• Review the current staffing arrangements to ensure all dental care professionals are adequately supported by a trained member of the dental team when treating patients in a dental setting, taking into account the guidance issued by the General Dental Council.
• Review its complaint handling procedures and establish an accessible system for identifying, receiving, recording, handling and responding to complaints by service users.
• Review the practice’s protocols for referral of patients to ensure all referrals are monitored suitably.
• Review the practice’s protocols for the use of rubber dam for root canal treatment taking into account guidelines issued by the British Endodontic Society.