We carried out a follow-up inspection on 9 October 2017 at Chelwood Dental Surgery.

We undertook an announced comprehensive inspection of this service on 8 February 2017 as part of our regulatory functions and during this inspection we found a breach of the legal requirements.

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.

We undertook a follow up inspection of Chelwood Dental Surgery on 9 October 2017. This inspection was carried out to check that improvements planned by the practice to meet legal requirements after our comprehensive inspection on 8 February 2017 had been made. We inspected the practice against one of the five questions we ask about services: is the service well-led? This is because the service was not meeting some of the legal requirements in relation to this question.

The inspection was carried out by a CQC inspector who had access to advice from a specialist dental advisor.

We carried out this follow-up inspection, by reviewing information sent to us by the practice telling us how the concerns identified during the comprehensive inspection had been addressed.

We have not revisited Chelwood Dental Surgery because the practice was able to demonstrate that they were meeting the standards without the need for a visit. We checked whether they had followed their action plan to confirm that they now met the legal requirements.

A copy of the report from our last comprehensive inspection can be found by selecting the 'all reports' link for Chelwood Dental Surgery on our website at www.cqc.org.uk.

Our findings were:

Are services

well-led

?

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

Background

Chelwood Dental Surgery is located in a residential area of Liverpool. The practice has two treatment rooms.

Access to the practice is by stairs only and patients who have mobility difficulties are directed to use other dental services within the area which are more accessible. There is parking available in the adjacent car park and on nearby streets.

The practice provides general dental care and treatment for adults and children an NHS or private basis.

The opening times are:

Monday to Friday 9:00am to 12:30pm and 2.00pm to 5:30pm

The practice team consists of three dentists, one dental hygiene therapist, and four dental nurses, one of whom is a trainee. The dental nurses also carry out reception duties.

The principal dentist is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. 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.

Our key findings were:

• The practice had introduced systems to review policies and risk assessments to ensure they were up to date.
• The practice had introduced systems to ensure quality and safety was monitored at the practice.
• The practice had improved the content of staff meetings to ensure learning was shared.

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

• Review the practice’s protocols to ensure actions identified in risk assessments, audits and staff meetings are completed and the resulting improvements can be demonstrated.

We carried out an announced comprehensive inspection on 8 February 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

Chelwood Dental Surgery is located on the first floor of the building, situated above shops within a residential area of Liverpool. The practice comprises of two treatment rooms, a decontamination room, a reception area, waiting room, and toilet and storage area. Access to the practice is by stairs only and patients who have mobility problems are directed to use other dental services within the area which are more accessible. There is parking available in the adjacent car park and on nearby streets.

The practice provides general dental treatment to patients predominantly on an NHS basis but also patients on a private basis. The opening times are:

Monday-Friday 9:00am -12:30pm and 2pm - 5:30pm

The practice is staffed by three dentists, two dental hygiene therapists, and four dental nurses, two of whom are trainees. The dental nurses also carry out reception duties.

The principal dentist is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. 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.

We received feedback from 26 people during the inspection about the services provided. Patients were positive about all aspects of the care and treatment. Patients commented that they found the practice very good and that staff were excellent, friendly, and caring. They said that they were always given helpful, honest explanations about dental treatment, and that the clinicians listened to them. Patients commented that the practice was clean and comfortable. Treatments were described by patients as excellent and appointments were always easy to obtain, including emergency appointments. Patients commented they were made to feel at ease, particularly when they were anxious about visiting the dentist.

Our key findings were:

• The practice had procedures in place to record accidents and incidents, however significant events were not always recorded and analysed and learning from them was not always shared with staff.
• Staff demonstrated knowledge and awareness of safeguarding, some had received appropriate training, and they knew the processes to follow to raise concerns. Safeguarding policies and procedures were in need of updating to reflect relevant legislation and guidance.
• There were sufficient numbers of suitably qualified and skilled staff to meet the needs of patients.
• The premises were clean and secure.
• Staff followed current infection control guidelines for decontaminating and sterilising instruments.
• Patients’ needs were assessed, and care and treatment were delivered, in accordance with current legislation, standards, and guidance.
• Patients received information about their care, proposed treatment, costs, benefits, and risks and were involved in making decisions about it.
• Staff were supported to deliver effective care.
• Patients were treated with kindness, dignity, and respect, and their confidentiality was maintained.
• The appointment system met the needs of patients, and emergency appointments were available.
• The practice gathered the views of patients and took their views into account.
• Staff had been trained to deal with medical emergencies, and emergency medicines and equipment were available and checked for working order and expiry dates
• The practice lacked good governance arrangements. Policies and procedures were not regularly updated, individual training plans were not evident and training was not monitored.
• Risks were assessed, however the risk assessments were not always up to date and actions to mitigate these risks were not evident.
• Audits were not effective as they did not demonstrate actions or improvements.

We identified a regulation that was not being met and the provider must:

• Ensure that practice policies and procedures are regularly reviewed and updates disseminated to staff, including health and safety, safeguarding and infection control policies and procedures.
• Ensure that risks are assessed, monitored and mitigated including health and safety, environmental, fire and Legionella.
• Ensure effective audits of various aspects of the service are undertaken at regular intervals to help improve the quality of service ensuring all audits have documented learning points and the resulting improvements can be demonstrated.
• Ensure that their audit and governance systems improve and remain effective.

You can see full details of the regulation not being met at the end of this report.

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

• Review the significant event policy and procedures to include identification and analysis of events and lessons learnt are reviewed and disseminated.
• Review the system for dealing with patient safety alerts and notices to include documenting actions taken appropriately.
• Review complaints and significant events annually or more frequently in order to identify themes and trends.
• Review staff induction to include formal induction processes that are documented.
• Review the practice’s safeguarding policy and staff training to ensure it is up to date and that all staff are trained to an appropriate level for their role and aware of their responsibilities.
• Review the implementation of staff meetings to ensure staff receive up to date information, training and dissemination of learning and that staff have an opportunity to share knowledge and ideas.
• Review staff appraisals to include regular review of training and development needs and support for staff.
• Review the practice training plan to include monitoring of staff training to ensure staff are all up to date with relevant and mandatory training.
• Review fire safety to include undertaking fire evacuation drills on a regular basis for all staff.