We carried out an announced comprehensive inspection at Allandale Dental Practice on 15 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 12 HSCA (RA) Regulations 2014 Safe care and treatment

Regulation 13 HSCA (RA) Regulations 2014 Safeguarding service users from abuse and improper treatment

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

On 22 November 2016 we carried out a follow up inspection 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. 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 Allandale Dental Practice on our website at cqc.org.uk

Background

The practice is situated in Hoole, Chester and has a reception/waiting room, a treatment room, a decontamination area and a storage area/administrative office. The practice has one dentist and a dental nurse. The practice provides primary dental services to private patients. The practice is open as follows:

Monday, Tuesday, Thursday and Friday 9am – 5pm

The principal dentist is the registered provider. A registered provider is a person who is registered as a ‘registered person’ with the Care Quality Commission. 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.

CQC inspected the practice on 15 March 2016 and asked the provider to make improvements in relation to:

• Ensuring the practice's recruitment policy and procedures were 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 were in place for all staff and the required specified information in respect of persons employed by the practice was held.

• Ensuring there were effective systems in place to assess the risk of and prevent, detect and control the spread of infections including a current legionella risk assessment, a cleaning schedule that was monitored and followed National Patient Safety Association (NPSA) guidance on the cleaning of dental premises, sharps handling procedures and protocols and hand wash to include wall mounted liquid hand wash dispensers were provided.

• Ensuring there were arrangements in place for receiving and responding to 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).

• Ensuring the practice’s safeguarding policies and staff training covers both children and adults and all staff are trained to an appropriate level for their role and aware of their responsibilities.

• Ensuring electrical safety tests and pressure vessel scheme of examinations are in place and carried out at the required intervals.

• Ensuring that appropriate fire safety training is carried out annually.

We checked these areas as part of this focussed inspection and found these had been resolved.

The findings of this review were as follows:

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

• Staff working at the practice had a Disclosure and Barring Service (DBS) check undertaken. However this was a basic level disclosure. Clinical staff roles should have an enhanced level disclosure undertaken appropriate to their role.
• A cleaning schedule was in place and monitored,
• A Legionella risk assessment had been undertaken and processes were in place to minimise the risk posed by the water systems.
• Wall mounted liquid hand wash dispensers were in place.
• Arrangements were in place to receive and act on patient safety alerts.
• The safeguarding policy and procedures had been revised and reissued and reflected current guidance. Staff had undertaken safeguarding training in relation to their role.
• Electrical safety tests, pressure vessel examinations, fire training and fire drills were now in place.

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

• Information on how to complain was included in the practice information leaflet.
• A business continuity plan had been implemented.
• The practice computers were password protected.
• A translation policy was in place
• An automated external defibrillator (AED) was in place and checked on a regular basis to monitor its working order

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

Review the recruitment policy to include an enhanced level of DBS check for all clinical staff roles.

We carried out an announced comprehensive inspection on 15 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 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 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 providing well-led care in accordance with the relevant regulations.

Background

The practice is situated on the outskirts of Chester city centre. The practice has one dentist and one dental nurse. The practice provides primary dental services to private patients only. The practice is open as follows:

Monday, Tuesday, Thursday and Friday 9am – 5pm

The principal dentist is the registered provider. A registered provider is registered with the Care Quality Commission to manage the service. 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.

We received feedback from 36 patients about the service. The 33 CQC comment cards seen and three patients spoken to reflected very positive comments about the staff and the service provided. Patients commented that they found the staff very caring, friendly and professional. They had trust and confidence in the dental treatments and said explanations from staff were clear and understandable.

Our key findings were:

• The practice recorded accidents and cascaded learning to staff when they occurred.
• Staff had been trained to deal with medical emergencies. Emergency medicines and emergency equipment were available; however the practice did not have access to an automated external defibrillator (AED).
• Infection prevention and control procedures were in place; however a Legionella risk assessment and cleaning schedule were not in place.
• Patients’ care and treatment was planned and delivered in line with evidence based guidelines and best practice.
• 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.
• The appointment system met the needs of patients, waiting times were kept to a minimum and there were sufficient staff to meet the needs of patients.
• There was a recruitment policy and procedures in place however this did not meet the requirements relating to workers and staff employed did not have evidence of references or Disclosure and Barring Service (DBS) checks in place.
• Electrical equipment had not been tested for safety and the pressure vessel (compressor) had not been serviced or maintained.
• There was no system in place for receiving and responding to patient safety alerts, recalls and rapid response reports.
• Staff had not received an appropriate level of safeguarding training and there was no policy or procedures in place for the protection of vulnerable adults.

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

• 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 there are effective systems in place to assess the risk of and prevent, detect and control the spread of infections including healthcare associated infections. Including a current legionella risk assessment, a cleaning schedule in that is monitored and follows National Patient Safety Association (NPSA) guidance on the cleaning of dental premises, sharps handling procedures and protocols and hand wash to include wall mounted liquid hand wash dispensers are provided.

• Ensure there are arrangements in place for receiving and responding to 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).
• Ensure the practice’s safeguarding policies and staff training covers both children and adults and all staff are trained to an appropriate level for their role and aware of their responsibilities.
• Ensure electrical safety tests and pressure vessel scheme of examinations are in place and carried out at the required intervals.
• Ensure that appropriate fire safety training is carried out annually.

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

• Review the practice’s system for the recording, investigating and reviewing of clinical incidents and significant events with a view to preventing further occurrences and, ensuring that improvements are made as a result.
• Review the complaints process so that it is publicised and patients are informed and supported to make complaints when appropriate.
• Review the implementation of a business continuity plan in order to minimise the risks and be able to respond to and manage major incidents and emergency situations.
• Review the practice information leaflet to inform patients of the services offered, opening times, costs, staffing and the complaints procedure. Publicise information for patients on how to access emergency dental care and treatment needed outside of normal practice working hours.
• Review the storage of dental care records to ensure they are stored securely and safely and that computer records are secure when not in use.
• Review the practice’s audit protocols of various aspects of the service, such as infection control and dental care records. The practice should check that all audits have documented learning points and the resulting improvements can be demonstrated.
• Review the availability of an interpreter service for patients who do not speak English as their first language.
• Review the availability of an automated external defibrillator (AED) 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.

We visited Allandale Dental Practice following receipt of information which led us to believe there may be issues in relation to infection control at the practice. We attended with a specialist adviser and spoke with the dentist (who is the provider and owner of the practice) and the practice nurse who had worked there for approximately eight months.

We spoke to a patient who attended the surgery on the day of our visit. They told us "The surgery is always nice and fresh and clean" and "The staff are always clean and tidy".

The dentist was the lead for infection prevention and control (IPC) and kept up to date with current practice by acting on guidance from the General Dental Council. He subscribed to a professional development on line package which provided up to date guidance related to dental practice. We found that the practice nurse also kept her professional development up to date and submitted details to the General Dental Council as required.

We saw that the dentist undertook regular self-assessments to check that the practice met the essential quality requirements of Health Technical Memorandum 01-05: Decontamination in primary care dental practices (HTM01-05). The HTM 01-05 is guidance designed to assist all registered primary dental care services to ensure that their practice meets satisfactory levels of decontamination.

We undertook a tour of the premises and found the reception area and treatment rooms to be clean and tidy. However we found that the whole dental practice facility required refurbishment to provide wall and floor coverings more suited to a healthcare environment. The dentist showed us an improvement plan he had drawn up which included total redecoration over a period of time.

At our previous inspection 14 March 2013, we had concerns because the practice did not employ a trained nurse. We found there was a lack of training and support for staff to enable them to carry out their role. In particular we were concerned that the dentist was not familiar with regulations and guidance for infection control and radiography. We saw the practice had a separate decontamination room but the relevant guidance for cleaning instruments was not followed. The machine to sterilize instruments (the autoclave) was old and had not received any safety checks. Similarly, the x-ray machine was old and the wiring to the machine was worn. There was no evidence of any safety checks and the practice was not complying with the ionising radiation (medical exposure) regulations for the safe use of x-rays in dental surgeries. We asked the dentist to send us an action plan to tell us how the practice would become compliant with the Health and Social Care Regulations 2008.

The purpose of this inspection was to check that the dentist was now compliant with the regulations. At this visit we found that there was now a dental nurse employed to assist the dentist and that the dentist had implemented a training programme for all staff.

We also found that the dentist had purchased new sterilizing and x-ray equipment and the practice followed recommended guidelines for infection control and the safe use of x-ray machines.

We spoke with three patients who told us staff were helpful and always treated them respectfully. One patient said: "The staff are very accommodating” and another told us: "I have always been very satisfied with the practice.”

We found that the written records did not contain all the relevant clinic information in relation to oral health assessments and treatment.

We saw evidence that the practice had a complaints policy in place and the patients we spoke with told us they had never had any reason to complain.

We saw the practice had a separate decontamination room but the relevant guidance for cleaning instruments was not followed. The machine to sterilize instruments (the autoclave) was old and had not received any safety checks. Similarly, the x-ray machine was old and the wiring to the machine was worn. There was no evidence of any safety checks and the practice was not complying with the ionising radiation (medical exposure) regulations for the safe use of x-rays in dental surgeries.

We found there was a lack of training and support for staff to enable them to carry out their role. In particular we were concerned that the dentist was not familiar with regulations and guidance for infection control and radiography.

There was no trained nurse in the surgery which meant there was no one to assist the dentist during any treatment or emergency which could put the patient at risk from harm.