We carried out a follow-up inspection at Dental Design studio on 26 October 2017.

We had undertaken an announced comprehensive inspection of this service on the 14 November 2016 as part of our regulatory functions where a breach of legal requirements was found.

After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach. This report only covers our findings in relation to those requirements. We checked whether they had followed their action plan to confirm that they now met the legal requirements.

We reviewed the practice against one of the five questions we ask about services: are the services well led? You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dental Design Studios on our website at www.cqc.org.uk.

We revisited Dental Design Studios as part of this review and checked whether they now met the legal requirements. We carried out this announced inspection on 26 October 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.

• Is it safe?
• Is it well-led?

This question forms the framework for the areas we look at during the inspection.

Our findings were:

Are the services safe?

We found that this practice was providing safe 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

Dental Design Studio is in the village of Edgeworth near Bolton and offers private general dental treatments and a range of cosmetic treatments for adults and children, including porcelain veneers, teeth whitening, implants and invisible braces. The practice has facilities for people with limited mobility, including an adapted toilet and ground floor treatment room.

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.

The practice is open:

Opening times: Mon: 9am-5.30pm; Tue: 9am-5.30pm; Wed: 9am-1.00pm; Thu: 9am-8pm; Fri: closed; Sat: 9am-12.30pm.

Our key findings were:

We identified regulations that the provided had acted upon :

• A Legionella risk assessment is now in place and actions undertaken.
• Medicines and Healthcare Products Regulatory Authority alerts (MHRA) are now received and any required action completed.
• Sharps handling procedures and protocols are now in line with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
• Radiation Regulations (IRR) 1999 and Ionising Radiation (Medical Exposure) Regulations (IRMER) 2000 have been reviewed and now follow relevant guidance.
• Risk assessments of all control of substances hazardous to health (COSHH) are now in place.
• Recruitment policy and procedures are in place and necessary employment checks for all staff completed.
• Audits of various aspects of the service, such as radiography and dental care records are now undertaken at regular intervals.
• Policies and procedures have been reviewed and updated.
• Risk assessments are in place to ensure equipment and the premises are clean and safe.

The practice had also acted upon other recommendations:

• Safeguarding training is now in place for staff.
• Emergency medicines and equipment were available in line with the guidance.
• Clinical waste is now segregated and disposed of in accordance with relevant regulations.
• A review of needs of people with a disability has now been completed.

We carried out an announced comprehensive inspection on 14 November 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.

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. We have told the provider to take action (see full details of this action in the Requirement Notices at the end of this report).

We will be following up on our concerns to ensure they have been put right by the provider.

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

Located in the village of Edgeworth near Bolton, Dental Design Studio offers private general dental treatments and a range of cosmetic treatments for adults and children, including porcelain veneers, teeth whitening, implants and invisible braces. The practice has facilities for people with limited mobility, including an adapted toilet and ground floor treatment room.

Opening times: Mon: 9am-5.30pm; Tue: 9am-5.30pm; Wed: 9am-1.00pm; Thu: 9am-8pm; Fri: closed; Sat: 9am-12.30pm.

The practice owner is registered with the Care Quality Commission (CQC) as an individual. 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 reviewed the feedback from 33 patients on the day of our inspection. Patients were extremely positive about the staff and standard of care provided by the practice. Patients commented that they felt involved in all aspects of their care and found the staff to be helpful, respectful and friendly, and were treated in a clean and tidy environment.

Our key findings were

• The practice was visibly clean and free from clutter.
• A process was in place for recording incidents and accidents.
• The practice had a safeguarding policy and staff were aware on how to escalate safeguarding issues for children and adults should the need arise.
• Staff received annual medical emergency training.
• Patients could access urgent care when required.
• The practice was actively involved in promoting oral health.
• There were sufficient numbers of suitably qualified staff to meet the needs of patients.
• Patients received clear explanations about their proposed treatment, costs, benefits and risks, and were involved in making decisions about their treatment.
• Patients were treated with dignity and respect.
• The appointment system met patient’s needs.
• The COSHH file had not been reviewed or updated.
• The Radiation Protection File was incomplete.
• There was no recruitment policy and procedure in place.
• The governance system was not effective, including the portfolio of practice policies and audit activity.
• Confidential paper information was not always stored securely.
• The practice had insufficient risk assessments in place to assess the risks to patients and staff including, Legionella, fire, environmental risks and sharps.
• The practice did not have access to an automated external defibrillator.
• The practice did not have all the emergency medicines in line with the British National Formulary (BNF) guidance for medical emergencies in dental practice.

There were areas where the provider could make improvements and 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 appropriate measures to receive and action Medicines and Healthcare Products Regulatory Authority alerts (MHRA) pertinent to the dental practice environment.
• Ensure the practice’s sharps handling procedures and protocols are in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
• Ensure that the practice is compliant with its legal obligations under Ionising Radiation Regulations (IRR) 1999 and Ionising Radiation (Medical Exposure) Regulations (IRMER) 2000.
• Ensure the COSHH file for hazardous materials is reviewed to ensure it is up-to-date and risk assessments are in place for all hazardous materials used or stored at the premises.
• Ensure 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 audits of various aspects of the service, such as radiography and dental care records are undertaken at regular intervals to help improve the quality of service. The practice should also ensure all audits have documented learning points and the resulting improvements can be demonstrated.
• Ensure the practice reviews its policies and procedures to ensure they reflect current guidelines, and develop policies that are not currently in place.

• Ensure an effective system is established to assess, monitor and mitigate the various risks arising from undertaking of the regulated activities, including sufficient assessments and checks to be undertaken to ensure the premises and equipment are clean and safe.
• Ensure the storage of records relating to the management of regulated activities is in accordance with current legislation and guidance.

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

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

• Review the practice’s safeguarding training for staff; ensuring it covers training for both children and adult safeguarding and all staff are trained to an appropriate level for their role and aware of their responsibilities.
• Review availability of medicines and equipment to manage medical emergencies giving due regard to guidelines issued by the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.
• Review the storage of medicines requiring refrigeration to ensure they are stored in line with the manufacturer’s guidance and the fridge temperature is monitored and recorded.
• Review the practice’s waste handling policy and procedure to ensure waste is segregated and disposed of in accordance with relevant regulations giving due regard to guidance issued in the Health Technical Memorandum 07-01 (HTM 07-01).
• Review the availability of an interpreter service for patients who do not speak English as their first language.
• Review responsibilities of the needs of people with a disability and the requirements of the equality Act 2010 and ensure a Disability Discrimination Act audit is undertaken for the premises.

We spoke with six people using the service (patients) in the surgery, two members of staff and the dentist. All the patients we spoke with felt the staff treated them in a pleasant, friendly and respectful manner, and were good at making them feel comfortable and at ease. One person said, "The staff are lovely, very good people" and "They are very friendly but professional".

People's right to private discussions/consultations was upheld and there were rooms, other than the surgery in use at the time, where private discussions could take place. Patients felt they were given enough information about their treatment options, and the relevant fees, which enabled them to make choices. They said the dentist discussed these things properly with them. One patient said, "The dentist was very patient and explained everything thoroughly more than once".

Patients told us they were very satisfied with their dental treatment. One said, "I'm perfectly happy with the results of my treatment". Another said, "They are brilliant; no complaints whatsoever". We saw some written comments people had made. The dentist was described as 'a perfectionist', 'brilliant' and 'patient'. The other staff were praised for their friendliness and their ability to put people at ease.

Patients also thought the facilities and the premises were pleasant, modern, clean and hygienic. They had also observed the staff undertaking correct hygiene procedures such as hand washing and wearing gloves and masks.