We undertook a focused inspection of Prime Dental Surgery on 8 April 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 CQC inspector who was supported by a specialist dental adviser.

We undertook a comprehensive inspection of Prime Dental Surgery on 20 November 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 well led care and was in breach of Regulation 17 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 Prime Dental Surgery on our website www.cqc.org.uk.

As part of this inspection we asked:

• 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 (requirement notice only). We then inspect again after a reasonable interval, focusing on the area(s) where improvement was required.

Our findings were:

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 breach we found at our inspection on 20 November 2018.

Background

Prime Dental Surgery is in Sparkhill, Birmingham and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. The reception, waiting area and treatment room are on the ground floor. The patient toilet is accessible by using stairs. Parking is available on local side roads near the practice.

The dental team includes two dentists, three trainee dental nurses, one of whom also works on the reception, a receptionist and a part time practice manager. The practice also employs a management consultant to give advice, provide staff training and introduce policies and

procedures. The practice has one treatment room.

The practice is owned by a partnership 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 Prime Dental Surgery is the principal dentist.

During the inspection we spoke with the management consultant and looked at practice policies and procedures and other records about how the service is managed.

The practice is open: Monday to Friday 10am to 12.30pm and 2pm to 4.30pm. The practice is also occasionally open on a Saturday by appointment only.

Our key findings were:

• The provider’s sharps risk assessment included a separate document which listed details of all sharp instruments in use at the practice.

• Policies and procedures had been completed, implemented and had been discussed at staff meetings.

• The provider had not addressed all immediate actions identified on the fire risk assessment completed in May 2018. Building work was due to commence at the practice shortly and issues identified would be addressed at this time.

• Water temperatures were being recorded monthly in accordance with the recommendations of the legionella risk assessment.

• Infection prevention and control audits were being completed on a six-monthly basis with the last audit completed in November 2018.

• Some improvements were required with audit processes. A patient dental care record audit had been completed in January 2019 for one of the dentists working at the practice. The last radiography audit was dated January 2019.

• An up to date waste pre-acceptance audit was available on file.

• Product safety data sheets were available for all hazardous substances in use at the practice.

• Information was available in staff recruitment files as per Schedule three of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

• Practice meetings had been held monthly since November 2018.

• Emergency medicines were within their expiry date. The log that staff used to record expiry dates had been completed incorrectly for three items.

• Evidence that two of the three dental nurses employed had immunity against vaccine preventable infectious diseases was available. The results for one staff member were due.

• A copy of the practice complaints procedure was on display in the waiting room and was readily available to patients.

• The practice had reviewed its protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment.

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

• Review the practice’s protocols to ensure audits of radiography are undertaken at regular intervals to improve the quality of the service. The practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.

• Review the fire safety risk assessment and ensure that any actions required are complete and ongoing fire safety management is effective.

Prime dental surgery is in Sparkhill, Birmingham and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. The reception, waiting area and treatment room are on the ground floor. The patient toilet is accessible by using stairs. Parking is available on local side roads near the practice.

The dental team includes two dentists, two trainee dental nurses, one of whom also works on the reception, a receptionist and a part time practice manager. The practice also employs a management consultant to give advice, provide staff training and introduce policies and procedures. The practice has one treatment room.

The practice is owned by a partnership 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 Prime dental surgery is the principal dentist.

During the inspection we spoke with one dentist, two trainee dental nurses, one of whom was working on the reception desk. We also spoke with the management consultant employed by the practice who attended this inspection to provide support to staff. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open: Monday to Friday 10am to 12.30pm and 2pm to 4.30pm. The practice is also occasionally open on a Saturday by appointment only.

Our key findings were:

• The practice appeared clean and well maintained. Electrical installations were checked appropriately and a gas safety certificate was provided following this inspection.
• Rectangular collimators were not used on X-ray units to reduce dosage to patients.
• The provider had infection control procedures which reflected published guidance. There was no soap in the patient toilet.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available. Checks to ensure medicines and equipment were within their expiry date were not carried out effectively as staff had recorded information incorrectly.
• The practice had systems to help them manage risk to patients and staff although improvements were required.
• The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The provider had not followed staff recruitment procedures on each occasion and information was not available for all newly appointed staff in accordance with Schedule three of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider did not have assurances that clinical staff had immunity against vaccine preventable infectious diseases.
• 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.
• Staff were providing preventive care and supporting patients to ensure better oral health.
• The provider asked staff and patients for feedback about the services they provided.
• The practice had not received any formal written complaints within the last two years. The provider had not responded to negative feedback recorded on the NHS choices website. The practice did not make a copy of their complaints procedure readily available to patients.
• The provider had suitable information governance arrangements.

We identified regulations the provider was not complying with. They must:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulation/s the provider is not meeting are at the end of this report.

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

• Review the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment.

There are two dentists, a practice manager, dental nurse and a receptionist working at this small dental practice with one treatment room, which is located in a busy shopping area of Birmingham.

This review visit was discussed and arranged with the practice a few days in advance. This was to ensure that we had time to see and speak with staff working at the practice, as well as people registered with the practice where appropriate.

As part of our visit, we spoke with five people who were registered with the practice by telephone. We also spoke with one of the dentists and their staff about working at the practice.

People that used the practice told us that they were happy with the quality of treatment received. They felt they were given enough information about their treatment options and the relevant fees, and were able to ask all the questions they wanted to.

We found that people using this practice had completed satisfaction questionnaires and comments made in these included:-

‘Very professional staff. Receptionist is very friendly and she has always booked me in when I have a lot of pain.

Overall, very friendly staff and welcoming.

Dr. Nisar is very understanding dentist specially for the younger generation. I would recommend to all my friends to come and join.

No faults pleased with all the treatment.’

People told us that the practice was clean and tidy and had no concerns about hygiene standards.