We carried out a follow- up inspection on 7 October 2016 at Acre Lane Dental Care.

We had undertaken an announced comprehensive inspection of this service on 10 March 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 and we reviewed the practice against two of the five questions we ask about services: is the service safe and well-led?

We revisited Acre Lane Dental Care as part of this review and checked whether they had followed their action plan and to confirm that they now met the legal requirements.

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

However, there were areas where the provider could make improvements and should:

• Review the practice protocol for ensuring equipment is regularly serviced.

We carried out an announced comprehensive inspection on 10 March 2016 to ask the practice the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

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 providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this practice was providing caring service 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

Acre Lane Dental Care is located in the London Borough of Lambeth and provides NHS and private dental services.

The practice comprises of a dentist, receptionist and a nurse.

The premises consist of one treatment room, a decontamination room and a waiting area.

The principal dentist 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.

During the inspection we reviewed 48 completed CQC comment cards and spoke with three patients on the day of the inspection. The patients who provided feedback were positive about the care and treatment they received at the practice. They told us they were involved in all aspects of their care and found the staff to be friendly and helpful and they were treated with dignity and respect.

Our key findings were:

• The practice had suitable processes around reporting and discussion of incidents. Staff were trained and there was appropriate equipment to respond to medical emergencies.

• Patients told us that staff were caring and treated them with dignity and respect.

• There was equipment for staff to undertake their duties but there was limited evidence of regular maintenance of equipment such as that used for decontamination of used instruments and for radiography.

• The provider had not undertaken risk assessments to assess risk of fire, Legionella, health and safety or radiation.

• Appropriate governance arrangements were not in place and there was lack of a clear vision for the smooth running of the practice.

• Clinical audits were not being undertaken appropriately and were not contributing to improvements in quality of care delivery.

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

• Ensure the practice’s infection control procedures and protocols are suitable 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 the practice's recruitment policy and procedures are suitable and the recruitment arrangements ensure that where relevant, staff have continued registration with appropriate professional bodies.

• Ensure that the practice is in compliance with its legal obligations under Ionising Radiation Regulations (IRR) 99 and Ionising Radiation (Medical Exposure) Regulations (IRMER) 2000.

• Ensure regular maintence of equipment in line with manufacturers’ instructions and relevant guidelines.

• Ensure an effective system is established to assess, monitor and mitigate the various risks arising from undertaking of the regulated activities.

• Ensure systems are in place to assess, monitor and improve the quality of the service such as undertaking regular audits of various aspects of the service and ensuring that where appropriate audits have documented learning points and the resulting improvements can be demonstrated.

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

• Review it’s responsibilities as regards to the Control of Substance Hazardous to Health (COSHH) Regulations 2002 and, ensure all documentation is up to date and staff understand how to minimise risks associated with the use of and handling of these substances.