During our announced comprehensive inspection of this practice on the 29 June 2016, we found a breach of legal requirements in relation to the Health and Social Care Act 2008. Following this inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to regulation 17- Good Governance.

We undertook this focused inspection to check that the provider had followed their improvement plan and to confirm that they now met legal requirements. This report only covers our findings in relation to this requirement. You can read the report from our previous comprehensive inspection, by selecting the 'all reports' link for Burleigh Street Dentistry 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 adequate action had been taken to address the shortfalls identified at our previous inspection and the provider was now meeting the regulations.

We carried out an announced comprehensive inspection on 29 June 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

Burleigh Street dentistry provides mostly private general dentistry services to adults. The practice belongs to the Antwerp House Dental Group is one of seven practices owned by Mr Raj Wadhwani.

The practice has a small team of five part time staff consisting of a dentist, two dental hygienists, one dental nurse and a receptionist. There are two treatment rooms, a patient waiting area and a small reception area. It is situated in the centre of Cambridge in a busy shopping area. The provider leases the premises and is not planning to renew the lease once it expires in 2017. Plans are in place for the practice to merge with another of the provider’s practices close by.

The practice opens on a Wednesday from 8am to 3.30pm, and on Thursdays and Fridays from 8am to 5pm.

Our key findings were:

• There was no separate decontamination room, access to the practice was only available via a steep staircase, there was no plumbing for hot water and one treatment room had been out of operation since March 2016 due to a leaking skylight.

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.

• Staff had been trained to handle emergencies and appropriate medicines were readily available in accordance with current guidelines

• Staff had received training appropriate for their roles and were supported in their continued professional development

• Patients were treated in a way that they liked and information about them was managed confidentially.

• The practice had a programme of clinical and non-clinical audit in place.

• Staff felt well supported by the practice manager and the provider as a whole

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

• Ensure effective systems and processes are established to assess and monitor the service against the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and national guidance relevant to dental practice.

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

• Review the availability of 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 the protocol for completing accurate, complete and detailed records relating to employment of staff. This includes making appropriate notes of interviews and ensuring recruitment checks, including references, are obtained and recorded.

• Review the practice’s infection control procedures and protocols 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.

• Review the practice’s protocols for recording in the patients’ dental care records or elsewhere the reason for taking the X-ray and quality of the X-ray giving due regard to the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2000.

• Consider providing the hygienist with the support of an appropriately trained member of the dental team.

• Review the practice's protocols for completion of patients’ medical histories giving due regard to guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.

• Review the practice’s responsibilities to the needs of people with a disability and the requirements of the Equality Act 2010 and ensure a Disability Discrimination Act audit is undertaken for the premises.

• Review appraisal protocols to ensure that all clinicians working at the practice have their performance monitored and assessed.