We undertook a follow-up inspection of Dairyground Dental Practice on 19 March 2019. This inspection was carried out to review in detail the actions taken by the registered provider to improve the quality of care and to confirm that the practice was now meeting legal requirements.

The inspection was led by a CQC inspector who was supported by a specialist dental adviser.

We undertook a comprehensive inspection of Dairyground Dental Practice on 4 October 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We found the registered provider was not providing safe and well-led care and was in breach of regulations 12, 17 and 19 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 Dairyground Dental Practice on our website www.cqc.org.uk.

As part of this inspection we asked:

• Is it safe?

• Is it well-led?

When one or more of the five questions are 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 areas where improvement is required.

Our findings were:

Are services safe?

We found this practice was not providing safe care in accordance with the relevant regulations.

The provider had made several improvements in relation to the regulatory breaches we found at our inspection on 4 October 2018 but these did not fully address the shortfalls identified.

Are services well-led?

We found this practice was not providing well-led care in accordance with the relevant regulations. The provider had made some improvements in relation to the regulatory breaches we found at our inspection on 4 October 2018 but these did not fully address the shortfalls identified.

Background

Dairyground Dental Practice is in the village of Bramhall, close to Stockport, Greater Manchester, and provides NHS and some private treatment for adults and children.

The practice is not accessible for people who use wheelchairs and those with pushchairs due its access via a flight of stairs. Car parking spaces are available outside the practice, where the waiting time is limited to 90 minutes.

The dental team includes four dentists, one employed dental nurse, a locum dental nurse and a part-time receptionist. A practice manager works at the practice three days each week and also carries out reception duties. The practice has two treatment rooms.

The practice is owned by an individual who is the principal dentist at a sister practice. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.

During the inspection we spoke with one dentist, two dental nurses, the receptionist and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open from 8.30 to 1pm and from 2pm to 5.30pm Monday to Thursday. On Friday the practice is open from 8.30am to 1pm.

Our key findings were:

• The practice was visibly clean.

• There were some improvements in infection control procedures, but further work was required to ensure staff followed recognised guidance.

• There was a lack of oversight of work in the decontamination room; staff were not working in-line with recognised guidance.

• There was still no radiation protection file in place for staff to refer to. We found that recommended rectangular collimators were still not in use. The last service check on equipment, which is carried out every three years, had expired in 2017.

• Staff demonstrated that they understood their responsibilities for safeguarding vulnerable adults and children. All staff had received training to the required level and information on local area contacts was available to staff.

• We found records in relation to staff and recruitment were still incomplete.

• No changes had been made since our last inspection, in relation to protecting privacy of patients in particular, in relation to the mail received at the practice.

• Practice leadership had not improved. Staff were not fully supported when trying to bring about improvements required.

• There was no focus on improvement, for example, through audit.

• Improvements made in relation to information governance were insufficient.

We identified regulations the provider was not meeting. They must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure that only fit and proper persons are employed.

Full details of the regulations the provider is not meeting are at the end of this report.

There were areas where the provider could make improvements. They should:

• Review the practice’s responsibilities to take into account the needs of patients with disabilities and to comply with the requirements of the Equality Act 2010.

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

• Review the fire safety risk assessment and ensure that any actions required are complete and ongoing fire safety management is effective.

• Review the practice's protocols for medicines management including the prescribing of antibiotics to ensure this is in line with current guidance.

We carried out this unannounced inspection on 4 October 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a CQC inspector who was supported by a specialist dental adviser.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

These questions form the framework for the areas we look at during the inspection.

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 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

Dairyground Dental Practice is in the village of Bramhall, close to Stockport, Cheshire, and provides NHS and some private treatment for adults and children.

The practice is approached through the front door which leads to two flights of stairs. This means it is not accessible for people who use wheelchairs and those with pushchairs. Car parking spaces, are available outside the practice, where the waiting time is limited to 90 minutes.

The dental team includes four dentists, one permanently employed dental nurse, a locum dental nurse and two part-time receptionists. A practice manager works at the practice one day each week. The practice has two treatment rooms.

The practice is owned by an individual who is the principal dentist at a sister practice. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.

During the inspection we spoke with one dentist, two dental nurses, the receptionist and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.

We were able to speak with one patient following their treatment. They told us the standard of treatment was good and that they were pleased with the service provided.

The practice is open from 8.30 to 1pm and from 2pm to 5.30pm Monday to Thursday. On Friday the practice is open from 8.30am to 1pm.

Our key findings were:

• The standard of record keeping in respect of patient records was good.
• The practice did not appear clean or well maintained.
• The provider could not demonstrate that infection control procedures reflected published guidance.
• Staff knew how to deal with medical emergencies.
• Some medicines and life-saving equipment were available; items marked as being present in emergency equipment bags were missing.
• The practice did not have adequate systems in place to help them manage risk to patients and staff.
• Staff demonstrated that they understood their responsibilities for safeguarding vulnerable adults and children, but did not have access to supporting protocols to refer to when required.
• The provider did not have thorough staff recruitment procedures.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Staff treated patients with dignity and respect.
• More care was required to protect their privacy and personal information of patients in handling post to the practice.
• We saw evidence from the dentist we spoke with that the practice was providing preventive care and supporting patients to ensure better oral health.
• The appointment system met patients’ needs.
• The practice leadership was ineffective. There was no focus on issues that required addressing, or culture of continuous improvement.
• Some staff we spoke with did not feel involved and supported.
• Staff and patients were asked for feedback about the services provided. We saw limited evidence of this, or that when feedback was provided, it was acted on.
• There was no evidence available to demonstrate that the provider dealt with any complaints positively and efficiently.
• Information governance arrangements required improvement.

We identified regulations the provider was not complying with. They must:

• Ensure care and treatment is provided in a safe way to patients.
• Ensure patients are protected from abuse and improper treatment.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
• Ensure specified information is available regarding each person employed.

Full details of the regulations the provider is not meeting are at the end of this report.

There were areas where the provider could make improvements. They should:

• Review the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment. In particular, making the required declaration to the Health and Safety Executive to confirm all radiation equipment is used in compliance with applicable regulations.
• Review operational procedures for taking X-ray images, including the use of rectangular collimators as recommended in recognised guidance.

• Review the practice's responsibilities to take into account the needs of patients with disabilities and to comply with the requirements of the Equality Act 2010.

We carried out an inspection on 18 September 2013 and published a report setting out our judgement. We asked the provider to send us a report of the changes they would make to comply with the standard they were not meeting.

We have followed up to make sure that the necessary changes have been made and

found the provider is now meeting the standards included within this report.

We visited Dairyground Dental Practice as part of this review. We reviewed records and spoke to staff. We also asked the provider to send us information to support compliance. This confirmed that they were now meeting the regulations relating to the standards included within this report.

This report should be read in conjunction with the full inspection report.

During our announced inspection on 18 September 2013 we spoke to one of the two dentists working that day, the practice manager, two members of staff and two people who used the service.

They said that they were given options, informed about any associated risks in respect of their treatment and told the potential costs of each option if there were any.

People told us they were treated well at this practice and they were happy with the service provided. One person we spoke to said; "They are very professional and explain everything."

Both dental nurses we spoke to were unclear as to current national guidance on sterilising re-usable instruments and told us they had not received any formal training on infection control since their initial training three years previously.

We asked the practice manager to provide a copy of the practice's Statement of Purpose, they were unable to provide a copy and were unsure whether one existed.

We saw that the practice kept an incident book, however incidents were not always recorded in it and were recorded in staff files. This meant that an audit of incidents would be difficult to complete.

The people we spoke to told us that they had never had cause for complaint and if they did they would feel comfortable making one. One person said; “I would be comfortable making a complaint if I needed to.”