During our announced comprehensive inspection of this practice on 12 July 2016 we found a breach of legal requirements of to the Health and Social Care Act 2008 in relation to regulation 17- Good Governance.

We undertook this focused inspection to check that the provider now met legal requirements. This report only covers our findings in relation to these requirements. You can read the report from our previous comprehensive inspection by selecting the 'all reports' link for Brandon Dental Care- Mr Saleh at www.cqc.org.uk

Are services Well-led?

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

Key findings

• Overall, we found that effective action had been taken to address the shortfalls identified at our previous inspection and the provider was now compliant with the regulations.

We carried out an announced comprehensive inspection on 12 July 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

Brandon Dental Surgery provides primarily NHS dental treatment to children and adults. The practice has one dentist, two dental nurses, a part-time dental hygienist and a receptionist. A specialist visits to provide implants to patients about every three months. The premises consist of two treatment rooms, a small decontamination room, a patient waiting area and small reception area. The practice opens Monday to Friday from 9am to 5.30pm.

Our key findings were:

• We received consistently good feedback from patients about the quality of the practice’s staff and the effectiveness of their treatment.

• Staff had received safeguarding training, knew how to recognise signs of abuse and how to report it.

• The arrangements in place for identifying, recording and managing risk were not robust.

• The practice was visibly clean and well maintained. Infection control and decontamination procedures were good, ensuring patients’ safety.

• There was appropriate equipment for staff to undertake their duties, and equipment was well maintained.

• Patients could access routine treatment and urgent care when required.

• Patients received their care and treatment from well supported staff, who enjoyed their work.

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

• Ensure the practice has 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).

• Ensure the practice's recruitment process is 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 the practice’s sharps handling procedures and protocols are in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

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

• Review availability of medicines and equipment 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.

• Review fire safety systems so that staff regularly practice evacuating the building in the event of a fire, and ensure there is a comprehensive and updated fire risk assessment in place.

• Review the practice’s compliance with legal obligations under Ionising Radiation Regulations (IRR) 99 and Ionising Radiation (Medical Exposure) Regulation (IRMER) 2000

• Review the current legionella risk assessment and implement the required actions to ensure that risks are being managed with due regard to the guidelines issued by the Department of Health -Health Technical Memorandum 01-05: Decontamination in primary care dental practices.

• Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.

• Consider providing the dental hygienist with the support of an appropriately trained member of the dental team.
• Review the security of prescription pads in the practice.

• Review the availability of an interpreter service for patients who do not speak English as their first language.

• Introduce robust processes for reporting, recording, acting on and monitoring significant events, incidents and near misses.

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