We carried out an announced comprehensive inspection at Lakeside Orthodontics on 22 March 2016 and at this time breaches of legal requirements were found. After the comprehensive inspection the practice wrote to us and told us that they would take action to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

Regulation 17 HSCA (RA) Regulations 2014 Good governance

Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed

On 20 December 2016 we carried out a follow up review of this service under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was carried out to check whether the provider had completed the improvements needed and identified during the comprehensive inspection in March 2016.

We reviewed the practice against one of the five questions we ask about services: is the service well-led? This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Lakeside Orthodontics on our website at www.cqc.org.uk

We reviewed information Lakeside Orthodontics had sent us as part of this review, checked whether they had followed their action plan and to confirm that they now met the legal requirements.

Our findings were:

Are services well-led?

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

Background

The practice is situated in West Kirby, Wirral. It has a waiting/reception area, three treatment areas, a decontamination room, staff facilities and administrative offices. The practice has one principal specialist orthodontist, three orthodontic therapists, five qualified dental nurses and a practice manager. The practice is a specialist dental surgery providing orthodontic treatment to both adults and children. Orthodontics is specialist dental treatment that corrects irregularities of alignment of the teeth in order to improve position, appearance and function of crooked or abnormally arranged teeth. They provide these services predominantly to NHS patients and also to some private patients. The practice receives dental referrals from dental practices all over the North West of England and North Wales.

The practice is open:

Monday to Thursday 9am - 5.30pm and Friday 9am – 4pm

The principal orthodontist is registered with the Care Quality Commission (CQC) as an individual and is legally responsible for making sure that the practice meets the requirements relating to safety and quality of care, as specified in the regulations associated with the Health and Social Care Act 2008.

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Our key findings were:

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

• A recruitment policy had been implemented that included obtaining the required information for people working at the practice such as photographic identification, references, qualifications and Disclosure and Barring Service (DBS) checks.
• Staff now have signed contracts and job descriptions reflective of their role.

Governance arrangements included:

• An audit programme was planned and included audits such as infection prevention and control, radiographs and clinical waste.

• Risks such as infection prevention and control, radiation, fire and Legionella had been assessed and action taken to mitigate the risks.
• A patient satisfaction survey had been undertaken.
• Paper patient records were stored securely.

We found that the practice had acted upon other recommendations made at the previous inspection to improve the service and care. For example:

• Staff had undertaken safeguarding training at a level relevant to their role and a revised safeguarding policy was in place that included vulnerable adults.
• Staff had been appraised and a mandatory training schedule had been implemented which would be monitored.
• The cleaning policy reflected national guidance on the cleaning of dental premises.
• The business plan has been reissued and staff had signed to say they read and understood it.

We carried out an announced comprehensive inspection on 22 March 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 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

The practice is situated in West Kirby, Wirral and has a waiting/reception area, three treatment areas, a decontamination room, staff facilities and administrative offices. The practice is furbished to a high standard and is currently undergoing building work to further improve facilities. The practice has one principal orthodontist, three orthodontic therapists, five qualified dental nurses and a practice manager. The practice is a specialist dental surgery providing orthodontic treatment to both adults and children. Orthodontics is specialist dental treatment that corrects irregularities of alignment of the teeth in order to improve position, appearance and function of crooked or abnormally arranged teeth. They provide these services predominantly to NHS patients and also to some private patients. The practice receives dental referrals from dental practices all over the North West of England and North Wales.

The practice is open:

Monday to Thursday 9am - 5.30pm and Friday 9am – 4pm

The principal dentist is the registered provider. A registered provider is a person who is registered with the Care Quality Commission to manage the service. Like registered managers, 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 received feedback from 52 patients about the service. The 49 CQC comment cards seen and three patients spoken to reflected very positive comments about the staff and the services provided. Patients commented that the practice appeared clean, hygienic and tidy and they found the staff very caring, friendly, approachable and professional. They had trust and confidence in the dental treatments and said explanations from staff were clear and understandable. They told us they were given time and made to feel at ease and would highly recommend the practice.

Our key findings were:

• The practice reported and recorded accidents and complaints. They had a significant incident and near misses policy and procedures in place; however there had been no recorded events.
• There were arrangements in place for receiving 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). However there was no documented evidence of response or action taken to these.
• Staff had not received a sufficient level of safeguarding training for their role or ongoing update training in safeguarding. However they were knowledgeable in safeguarding and protection of children and vulnerable adults and had access to local authority policies and procedures. The practice responded and staff completed an online course shortly after the inspection.
• Recruitment policies and procedures were not in place and recruitment checks had not been undertaken as required. Review of staff performance and training and development needs were not undertaken on a regular basis.
• Staff had been trained to deal with medical emergencies and emergency medicines and emergency equipment were available, maintained and checked.
• Infection prevention and control procedures were in place; however a valid Legionella risk assessment, autoclave validation and cleaning schedules were not in place. The practice responded immediately and put control measures in place.
• When X-Rays were taken, they were justified, quality assured and reported on. X-rays were taken in line with current guidelines by the Faculty of General Dental Practice of the Royal College of Surgeons of England and national radiological guidelines.
• Patients’ care and treatment was planned and delivered in line with evidence based guidelines, best practice and current legislation within their specialist field.
• Patients had their treatment peer assessed and rated using the orthodontic peer assessment rating (PAR) index. Staff were trained and calibrated in PAR. (The PAR index is a robust way of assessing the standard of orthodontic treatment that an individual provider is achieving and determining the outcome of the orthodontic treatment in terms of improvement and standards).
• Patients received clear explanations about their proposed treatment, costs, benefits and risks and were involved in making decisions about it.
• Patients were given routine extended appointments and appointments to suit individual needs.
• Patients were treated with dignity and respect and their confidentiality was maintained.
• The appointment system met the needs of patients and extended appointments were given routinely.
• The practice staff felt valued, involved and worked as a team.
• A complaint handling policy and procedures were in place for identifying, receiving, recording, handling and responding to complaints by patients.
• There was a lack of a robust governance framework for the smooth running of the practice; They responded and told us they would review governance arrangements to include audits of quality and safety, ensuring policies, procedures and risk assessments were localised, reviewed and up to date and encourage and act on feedback from patients, public and staff.

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

• Ensure the practice's recruitment policy and procedures are established 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 robust governance arrangements are established and operated to assess, monitor and improve the quality and safety of services provided and seek and act on feedback from patients and other relevant persons.
• Ensure robust governance arrangements are in place to ensure risks to the health and safety of patients and others are assessed, monitored and mitigated, including ensuring infection prevention and control risks (such as Legionella), radiation risks and general environmental risks are implemented, monitored and reviewed appropriately.
• Ensure the storage of paper records to minimise the risk of environmental damage and security and check they are stored safely and meet health and safety and fire regulations in accordance with the Department of Health’s code of practice for records management (NHS Code of Practice 2006) and other relevant guidance about information security and governance.

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

• Review the practice’s safeguarding policies and staff training to cover both children and adults with training at an appropriate level to their role.
• Review the training, learning and development needs of staff members at appropriate intervals and establish an effective process for the on-going assessment and supervision of all staff employed which includes ensuring staff are up to date with mandatory training including safeguarding and fire safety.
• Review and document the cleaning schedule to consider following National Patient Safety Association (NPSA) guidance on the cleaning of dental premises.
• Review the implementation of the business continuity plan so that staff are familiar with its contents and it is accessible.

No information was obtained from the people using the service during the visit.

A quality assurance survey was carried out in 2009 to obtain the views of the people using the service about the treatment and service they received. A selection of questionnaire were looked at. They indicated that people were overwhelmingly happy with all aspects of the service they received.