We carried out an announced comprehensive inspection of this practice on 31 March 2016. A breach of legal requirement was found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to Regulation 17 HSCA (RA) Regulations 2014 Good Governance.

We undertook a focused inspection of Marsh Hill Dental Surgery on 18 July 2017. This was to follow up on actions we asked the provider to take after our announced comprehensive inspection.

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 Marsh Hill Dental Surgery on our website at www.cqc.org.uk

Our findings were:

Are services well-led?

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

Background

Marsh Hill Dental Surgery Centre is a general dental practice which offers predominantly NHS and some private dental treatment to adults and children.

The premises are located on the ground floor and consist of one treatment room and a reception/waiting area. The decontamination of dirty dental instruments is carried out in the treatment room as the practice does not have a designated decontamination room.

The practice is open Mondays and Tuesdays from 9am to 3pm, on Thursdays it is open from 9am to 2pm and on Fridays it is open from 9am to 1pm. On Wednesdays reception is open for bookings only from 9am to 1pm.

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 practice manager and the dental nurse. We looked at practice policies and procedures and other records about how the service is managed.

Our key findings were:

• Improvements were seen in most areas where concerns had been highlighted in our previous comprehensive inspection.
• The practice’s recruitment policy, procedures and the recruitment arrangements had been reviewed.
• The practice had put processes in place to establish a system to assess, monitor and mitigate the various risks arising from undertaking the regulated activities.

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

• Review the condition of flooring, cabinetry and fittings and ensure that repairs and replacements are incorporated into future refurbishment plans. The practice should arrange to promptly carry out remedial repairs until the refurbishment.
• Review their cleaning schedules and the effectiveness of these in the practice.

We carried out an announced comprehensive inspection on 31 March 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

Marsh Hill Dental Surgery Centre is a general dental practice which offers predominantly NHS and some private dental treatment to adults and children.

The premises are located on the ground floor and consist of one treatment room and a reception/waiting area. The decontamination of dirty dental instruments were carried out in the treatment room as the practice did not have a designated decontamination room.

The practice was open Mondays and Tuesdays from 9am to 3pm, on Thursdays it was open from 9am to 2pm and on Fridays it was open from 9am to 1pm. On Wednesdays reception was open for bookings only from 9am to 1pm.

The provider owned two other local sister practices nearby and staff members were not permanently based at this practice but also worked at the nearby sister practices. Normally the provider and another associate dentist worked at the practice with a dental nurse and reception staff. There was a practice manager/area manager who was responsible for the overall governance of the practice but they were not based at this site. On the day of the inspection an assistant practice manager told us that they helped the practice manager with the day to day running of the practice and usually worked at this site once a month.

The provider is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. 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.

Before the inspection we sent Care Quality Commission comment cards to the practice for patients to complete to tell us about their experience of the practice. We collected three completed cards and spoke with two patients. These provided a positive view of the services the practice provides. All of the patients commented that the quality of care was very good.

We carried out an announced comprehensive inspection on 31 March 2016 as part of our planned inspection of all dental practices. The inspection took place over one day and was carried out by a lead inspector and a dental specialist adviser.

Our key findings were:

• There was an induction and training programme for staff to follow which ensured they were skilled and competent in delivering safe and effective care and support to patients.
• The practice ensured staff maintained the necessary skills and competence to support the needs of patients.
• There were some systems in place to reduce the risk and spread of infection they were not adequate as we found some part of the practice visibly unclean. Patents commented that the practice needed updating as we saw some cupboard edging needed to be fixed to ensure effective cleaning. A fridge used to store an emergency medicine looked visibly dirty.
• There were systems in place to check equipment had been serviced regularly, including the dental air compressor, autoclaves, fire extinguishers, oxygen cylinder and the X-ray equipment.
• There was appropriate equipment for staff to undertake their duties, and equipment was well maintained. The practice had access to an automated external defibrillator (AED) but staff members were unable to demonstrate if it was working.
• The provider had emergency medicines on site in line with the British National Formulary (BNF) guidance for medical emergencies in dental practice. However, one of the medicines were being stored in a fridge and the temperatures were not being monitored to ensure it was within an acceptable range.
• Patients received clear explanations about their proposed treatment, costs, benefits and risks and were involved in making decisions about it.
• Patients were treated with dignity and respect and confidentiality was maintained.
• The appointment system met the needs of patients and waiting times were kept to a minimum.
• There was an effective system in place to act on feedback received from patients and staff.
• Governance arrangements were in place for the smooth running of the practice; however they were not robust as the practice did not have a structured plan in place to review policies and where appropriate they were being followed.

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

• Ensure an effective system to assess, monitor and improve the quality and safety of the services provided.
• Ensure that the practice is in compliance with its legal obligations under Ionising Radiation Regulations (IRR) 99 and Ionising Radiation (Medical Exposure) Regulation (IRMER) 2000.

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

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

• Review requirements relating to local rules for the X-ray machine to ensure they were signed and dated by relevant persons.
• Review the practice’s audit protocols of various aspects of the service, such as radiography and dental care notes.
• Review systems and processes that are in place to ensure effective cleaning.
• Review processes to ensure dental care records are maintained appropriately giving due regard to guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.
• Review preparedness to deal with medical emergencies during domiciliary visits by considering need for appropriate emergency equipment and drugs.
• Review the practice's recruitment policy and consider if procedures were suitable and the recruitment arrangements were in line with Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 to ensure necessary employment checks were in place for all staff and the required specified information in respect of persons employed by the practice was held.
• Review the RIDDOR policy to ensure information relating to designated lead roles reflects the current staff group.

The surgery was closed to patients when we carried out our inspection. During our inspection we spoke with the practice manager, a receptionist, a dental nurse and the principal dentist who had arrived towards the end of our inspection. We were told that the current provider had taken over the practice recently. The practice looked dated and the staff agreed that it needed updating. One person we spoke with said: “I think they could sell the place more”. The provider told us that they had plans to merge this practice with an existing surgery nearby. They were currently seeking peoples views in regards to the proposal.

Following our visit we spoke with five people over the telephone so that we could get their views of the service provided. Everyone we spoke with was very positive about the level of care. One person said: “Very good, very pleasant”. Another person said: “I have confidence in her (an associate dentist)”.

We found that people received the planned care and treatment they needed and records detailed the treatment people had received.

There were infection prevention procedures in place and nominated individuals to ensure they were being followed to minimise the risk of infection.

Staff had received appropriate training and development to enable them to deliver treatment to people safely and to an appropriate standard.

There were procedures in place to monitor quality of service and identify improvements where necessary.