We carried out a focused inspection of Castle Dental Practice on 14 November 2017.

The inspection was led by a CQC inspector who had access to telephone support from a dental clinical adviser.

We carried out this inspection focusing only on the well-led key question to check on information we had received relating to this aspect of care at this practice.

We carried out the inspection to follow up concerns we originally identified during a comprehensive inspection at this practice on 17 January 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions.

At a comprehensive inspection we always ask the following five questions to get to the heart of patients’ experiences of care and treatment:

• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well-led?

When one or more of the five questions is not met we require the service to make improvements and send us an action plan. We then inspect again after a reasonable interval, focusing on the area(s) where improvement was required.

At the previous comprehensive inspection we found the registered provider was providing safe, effective, caring and responsive care in accordance with relevant regulations. We judged the practice was not providing well-led care in accordance with 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 Castle Dental Practice on our website www.cqc.org.uk.

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 to put right the shortfalls and deal with the regulatory breach we found at our inspection on 17 January 2017.

We spoke with people who told us that the dental staff were helpful and the services dentists were “very good.” They told us the place was clean and they had been well informed about the dental treatment they were going to receive. One person told us how he needed emergency treatment once and found that dentist very helpful in arranging to be seen quickly.

We carried out an announced comprehensive inspection on 17 January 2017 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

Castle Dental Practice is a dental practice providing NHS and private treatment for both adults and children. The practice is based in a converted office based in Portchester, a town close to Portsmouth, in south Hampshire.

The practice has three dental treatment rooms all of which are based on the ground floor and a separate decontamination area used for cleaning, sterilising and packing dental instruments. The practice is accessible to wheelchair users, prams and patients with limited mobility.

The practice employs two dentists, one hygienist and three dental nurses who also cover reception.

The practice’s opening hours are between 8.30am and 7pm on Monday and Tuesday, 8.30am and 5pm on Wednesday and 8.30am and 12.30pm on Thursday and Friday.

There are arrangements in place to ensure patients receive urgent medical assistance when the practice is closed. This is provided by the principal dentist and an out-of-hours service, via 111.

Dr Martin Law, the principal dentist, is registered as an individual and is legally responsible for making sure that the practice meets the requirements relating to safety and quality of care, as specified in the regulations associated with the Health and Social Care Act 2008.

We obtained the views of nine patients on the day of our inspection.

Our key findings were:

• We found that the practice ethos was to provide patient centred dental care in a relaxed and friendly environment.
• Clinical leadership was provided by the principal dentist.
• Appropriate emergency medicines and life-saving equipment were available in accordance with current guidelines.
• The practice appeared clean and well maintained.
• There was appropriate equipment for staff to undertake their duties, and equipment was maintained.
• Infection control procedures generally followed published guidance.
• The practice had processes in place for safeguarding adults and children living in vulnerable circumstances.
• There was a process in place for the reporting and shared learning when untoward incidents occurred in the practice.
• Dentists provided routine dental care in accordance with current professional guidelines.
• The practice carried out intravenous sedation for a small number of patients each year. We found shortfalls in the clinical governance systems that underpinned the provision of conscious sedation.
• The service was aware of the needs of the local population and took these into account in how the practice was run.
• Patients could access treatment and urgent and emergency care when required.
• The practice had some clinical governance and risk management structures in place, but we found several shortfalls in systems and processes.
• Areas where we found that required improvements were the governance systems underpinning the health and safety systems including fire, infection control, practice records, conscious sedation, safer sharps usage, medicines management and clinical audit.
• Information from 50 completed Care Quality Commission (CQC) comment cards gave us a positive picture of a friendly, caring, professional and high quality service.

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

• Ensure the training, learning and development needs of staff members are collated and reviewed at appropriate intervals.
• Ensure risk assessments in key areas such as infection prevention and control, recapping needles following administration of local anaesthetic and sedation are carried out.
• Ensure written policies and procedures are reviewed regularly and updated to reflect changes in legislation and guidelines.
• Ensure there is a robust system to record, respond and learn from significant events and accidents.
• Ensure that the governance arrangements for sedation take into account the guidance set out in the Department of Health document, conscious sedation in the provision of dental care 2003.
• Ensure staff assisting in conscious sedation have the appropriate training and skills to carry out the role.
• Ensure medicines dispensing follow the secondary dispensing guidelines of the British Pharmacological Society.

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

• Review the practice’s infection control procedures and protocols taking into account The Health and Social Care Act 2008: Code of Practice about the prevention and control of infections and related guidance. Specifically, the review the use of residual protein testing for the ultrasonic cleaning bath.
• Provide an annual statement in relation to infection prevention control required under 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 completion of dental records giving due regard to guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.
• Review the monitoring frequency of the emergency oxygen and automated external defibrillator so that they are reviewed at least weekly rather than on the existing monthly arrangements.
• Review the safety arrangements of the window blinds in the practice, this could include either ensuring the pull cords are made secure or carrying out a suitable risk assessment in relation to the pull cords.
• Consider the provision of an external name plate providing details of the dentists working at the practice including their General Dental Council (GDC) registration number in accordance with GDC guidance March 2012.
• Review the contents of the practice website, practice leaflet and NHS Choices to bring information up to date.
• Review the storage arrangements of the emergency medicines and lifesaving equipment so that they are stored in one central location in the practice.
• Review the security of the decontamination room which contained prescription only medicines to prevent unauthorised access by the public.
• Review the practice’s arrangements 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).