We carried out a follow- up inspection on 19 December 2016 at Cray Dental Care.

We had undertaken an announced comprehensive inspection of this service on 21 March 2016 as part of our regulatory functions where a breach of legal requirements was found.

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 and we reviewed the practice against three of the five questions we ask about services: is the service safe, effective and well-led?

This was a desktop review and we did not revisit Cray Dental Care as part of this review. We checked whether they had followed their action plan and requested documents from the provider to confirm that they now met the legal requirements.

We found that this practice was now providing safe, effective and well-led care in accordance with the relevant regulations.

We carried out an announced comprehensive inspection on 21 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 not 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

Cray Dental Practice is located in St Marys Cray, Orpington, Kent. The practice consists of two treatment rooms, a waiting room, reception area and patient toilet. All the facilities are situated on the first floor. There is a car parking available at the rear of the surgery. The practice is not suitable for wheelchair access.

The practice provides private and NHS dental treatment to children and adults. The practice offers a range of dental treatments such as routine examinations, general dental treatments, oral hygiene care, and restorative treatments such as veneers, crowns, bridges and implants.

The practice is open Monday – Wednesday 9am-5.30pm, Thursday 9am-7pm and Friday 9am-4.30pm. The staff structure consists of a two principal dentists, three dental nurses, one receptionist.

One of the principal dentists is the registered manager. A registered manager is a person who is registered with the Care Quality Commission (CQC) 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.

The inspection took place over one day and was carried out by a CQC inspector and a dental specialist advisor.

We received 36 CQC comment cards completed by patients and spoke with four patients during our inspection visit. Patients we spoke with, and those who completed comment cards, were positive about the care they received from the practice. They were complimentary about the staff and the treatment they had received and told us they were able to access appointments easily. We were told the staff were friendly and professional at all times.

Our key findings were:

• There was a system in place for reporting incidents and staff understood the process for accident and incident reporting.
• There were arrangements in place to meet the Control of Substances Hazardous to Health 2002 (COSHH) regulations.
• There were systems in place to reduce the risk and spread of infection.
• 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 and confidentiality was maintained.
• The appointment system met the needs of patients and waiting times were kept to a minimum.
• Improvements were required to ensure patients’ care was planned in line with current guidance such as from the National Institute for Health and Care Excellence (NICE).
• The practice did not have suitable arrangements in place to deal with medical emergencies.
• The practice did not have an effective safeguarding process in place and staff had not undertaken recent training for safeguarding vulnerable adults and children.
• Equipment, such as the air compressor, autoclave (steriliser), fire extinguishers had all been checked for effectiveness and had been regularly serviced.
• There were insufficient checks, staff training and auditing of X-rays and equipment in line with IR(ME)R 2000.
• Governance arrangements and audits were not effectively carried out to monitor and improve the quality and safety of the services.

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

• Ensure that all of the staff had undergone relevant training, to an appropriate level, in the safeguarding of children and vulnerable adults.

• 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 that the practice is in compliance with its legal obligations under Ionising Radiation Regulations (IRR) 99 and Ionising Radiation (Medical Exposure) Regulations (IRMER) 2000.

• Ensure regular maintenance of equipment in line with manufacturers’ instructions and relevant guidelines.

• Ensure the practice undertakes a Legionella risk assessment and implements the required actions 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.’

• Ensure the training, learning and development needs of individual staff members are reviewed at appropriate intervals and an effective process is established for the on-going assessment and supervision of all staff.

• Ensure staff are up to date with their mandatory training and their Continuing Professional Development (CPD).

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

• Ensure systems are in place to assess, monitor and improve the quality of the service such as undertaking regular audits of various aspects of the service and ensuring that where appropriate audits have documented learning points and the resulting improvements can be demonstrated.

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 British National Formulary, the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.

• Review practice protocols for patient assessments and ensure they take into account current legislation and consider relevant nationally recognised evidence-based guidance.

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

• 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 (IRMER) 2000.

We spoke to three people who used the service. One had been coming to the practice for five years and said they were "Brilliant", easy to get appointments, good on the telephone and gave her information about charges in advance.

The second person had moved away but travelled back for her dental appointments as they were "very good dentists". She told us about her son who could only be treated with sedation at another practice, but at this practice they spent time with him and could treat him now without sedation.

The third person had been coming to the practice for over 20 years. He was very happy with the practice and was always given treatment options, informed about fees, staff always wore gloves, masks and eye protection and the receptionists were very friendly.