We undertook a follow up focused inspection of Dental Practice - Barkingside on 11 April 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 Dental Practice - Barkingside on 14 November 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, effective or well led care and was in breach of regulation 12 - Safe care and treatment, 17 – Good governance, 18 - Staffing and 19 - Fit and proper persons employed 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 Dental Practice - Barkingside on our website www.cqc.org.uk.

• Is it safe?

• Is it effective

• 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 was required.

Our findings were:

Are services safe?

We found that this practice was providing safe care in accordance with the relevant regulations. The provider had made improvements in relation to the regulatory breach we found at our inspection on 14 November 2018.

Are services effective

We found that this practice was providing effective care in accordance with the relevant regulations. The provider had made improvements in relation to the regulatory breach we found at our inspection on 14 November 2018.

Are services well-led?

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

The provider had made improvements in relation to the regulatory breach we found at our inspection on 14 November 2018.

Background

Dental Practice - Barkingside is in Ilford in the London Borough of Redbridge. The practice provides NHS and private treatments to patients of all ages. The practice is situated close to public transport bus services.

The dental team includes the principal dentist who owns the practice, one associate dentist, one specialist periodontist and two dental nurses.

The practice is owned by an individual who is the principal dentist there. 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 the principal dentist, one associate dentist and two dental nurses.

We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Friday from 9am to 5.30pm.

Our key findings were:

• There were arrangements to assess and mitigate risks of infection. There were systems to ensure that single use dental instruments were disposed of and not available for re-use. Clinical waste was disposed of properly and safely.

• There were arrangements in place for ensuring that all relevant staff had suitable immunity against vaccine preventable infectious diseases. The practice’s sharps procedures were in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

• There were arrangements to assess and mitigate risks associated with infection prevention and control and Legionella.

• There were arrangements to monitor and improve quality in relation to dental radiography though a system of audits.

• There were processes in place to ensure the on-going supervision and appraisal for staff.

• There were systems in place to ensure that staff undertook training and periodic training updates in areas relevant to their roles including training in safeguarding children and vulnerable adults and training in infection control.

• There were processes to ensure that appropriate checks were carried out including determining for each person employed their identity, employment history, proof of conduct in previous employment and registration with their appropriate professional body.

• There were systems to ensure that dental care products and medicines requiring refrigeration were stored in line with the manufacturer’s guidance.

• There were arrangements to minimise risks associated with the use and handling of hazardous substances, taking into account the Control of Substances Hazardous to Health (COSHH) Regulations 2002.

• The practice had protocols for the use of rubber dam for root canal treatment taking into account guidelines issued by the British Endodontic Society.

• Information in relation to safety including patient safety alerts, recalls and rapid response reports issued from the Medicines and Healthcare products Regulatory Agency (MHRA) were reviewed and shared to help monitor and improve safety.

• Improvements had been made to the practice's protocols for completion of dental care records taking into account guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.

• There were systems to ensure that urgent and routine referrals were monitored suitably.

• Improvements had been made to the arrangements to respond to the needs of patients with disability and the requirements of the Equality Act 2010.

We carried out this announced inspection on 14 November 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection in response to concerns we received and 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 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

Dental Practice - Barkingside is in Ilford in the London Borough of Redbridge. The practice provides NHS and private treatments to patients of all ages.

The practice is situated close to public transport bus services.

The dental team includes the principal dentist who owns the practice, one associate dentist, one specialist periodontist and two trainee dental nurses.

The practice is owned by an individual who is the principal dentist there. 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.

On the day of inspection we received feedback from 25 patients.

During the inspection we spoke with the principal and two trainee dental nurses.

We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Friday from 9am to 5.30pm.

Our key findings were:

• Staff knew how to deal with emergencies.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• The appointment system met patients’ needs.
• The practice appeared generally clean and well maintained.
• The practice infection control procedures did not reflect published guidance. Staff did not have appropriate infection prevention and control training. Clinical waste was not disposed of suitably and staff did not have suitable immunity against vaccine preventable infectious diseases.
• The practice had limited systems to help them manage risk. There were no Legionella or sharps risk assessments available. Risk assessments that were carried out were not completed properly nor used to help understand and mitigate the risks.
• The practice had arrangements for the safe use of medicines and equipment. Improvements were needed so that the dentists used a rectangular collimator taking into account Guidance Notes for Dental Practitioners on the Safe Use of X-ray Equipment and that temperature sensitive medicines requiring refrigeration were stored appropriately.
• The practice had safeguarding processes and staff knew their responsibilities for safeguarding adults and children. Not all staff had completed safeguarding training.
• The practice staff recruitment procedures were not followed so that all of the essential checks were carried out. Staff were not suitably trained or supported to carry out their duties.
• The clinical staff did not always provide patients’ care and treatment in line with current guidelines.
• The practice was not providing preventive care and supporting patients to ensure better oral health.
• There was ineffective leadership and a lack of clinical and managerial oversight for the day-to-day running of the service.
• The practice did not have suitable information governance arrangements.

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 persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

• 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

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

• Review the storage of dental care products and medicines requiring refrigeration to ensure they are stored in line with the manufacturer’s guidance and the fridge temperature is monitored and recorded.
• Review the practice’s systems in place for environmental cleaning taking into account current national guidelines.
• Review its responsibilities as regards the Control of Substances Hazardous to Health (COSHH) Regulations 2002 and ensure all documentation is up to date and staff understand how to minimise risks associated with the use and handling of these substances.
• Review the practice’s protocols for the use of rubber dam for root canal treatment taking into account guidelines issued by the British Endodontic Society.
• Review the protocols and procedures for use of X-ray equipment taking into account Guidance Notes for Dental Practitioners on the Safe Use of X-ray Equipment. This relates specifically to the use of rectangular collimation.
• 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).
• Review the practice's protocols for completion of dental care records taking into account guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.
• Review practice protocols for patient assessments and ensure they are in compliance with current legislation and take into account relevant nationally recognised evidence-based guidance.
• Review the practice’s protocols for referral of patients and ensure urgent referrals are monitored suitably.
• Review the practice’s protocols and procedures for promoting the maintenance of good oral health taking into account guidelines issued by the Department of Health publication ‘Delivering better oral health: an evidence-based toolkit for prevention’
• Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.
• Review staff awareness of Gillick competency and ensure all staff are aware of their responsibilities.
• Review its responsibilities to the needs of people with a disability, including those with hearing difficulties and the requirements of the Equality Act 2010.
• Review the practice’s protocols for referral of patients and ensure urgent referrals are monitored suitably.

We carried out an announced comprehensive inspection of this service on 18 November 2015 as part of our regulatory functions where a breach of legal requirements was found.

We carried out a follow- up inspection on 16 March 2016 to check that they had followed their plan and to confirm that they now met the legal requirements. This report only covers our findings in relation to those requirements. We revisited Dental Practice - Barkingside as part of this review.

You can read the report from our last comprehensive inspection by selecting the 'all reports' link for Dental Practice - Barkingside on our website at www.cqc.org.uk.

We carried out an unannounced comprehensive inspection on 18 November 2015 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.

Dental Practice – Barkingside is located in the London Borough of Redbridge. The practice is on two floors, with one treatment room and a patients’ toilet on the ground floor and another treatment room on the first floor. There is also a reception and waiting area.

The practice provides NHS and private dental services and treats both adults and children. The practice offers a range of dental services including routine examinations and treatment.

The staff structure of the practice comprises of the principal dentist, an associate dentist, a specialist dentist, a dental nurse and two trainee dental nurses. The practice was open Monday to Friday from 9.am-5.30pm and Saturday from 9am-1pm.

The principal dentist is registered with the Care Quality Commission (CQC) as an individual. 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 were unable to review Care Quality Commission (CQC) comment cards completed by patients as this was an unannounced inspection. We did review feedback from patients who had completed the ‘Friends and Family Test’ comment cards and found that the feedback was mostly positive.

Our key findings were:

• Patients were able to make routine appointments and emergency appointments when needed.

• Equipment, such as the air compressor, autoclave (steriliser), and X-ray equipment had all been checked for effectiveness and had been regularly serviced.

• Patients indicated on the ‘Friends and Family Test’ comment cards that they felt they were listened to and that they mostly received good care from the practice team.

• There was a complaints procedure available for patients.

• Patients’ needs were not always assessed and care not planned in line with best practice guidance, such as from the National Institute for Health and Care Excellence (NICE).
• Staff were not aware of following the correct protocols while cleaning and decontaminating used dental instruments.

• Medicines and equipment to manage medical emergencies was not available on the day of the inspection.
• Governance arrangements were limited and the practice did not have a structured plan in place to assess various risks arising from undertaking the regulated activities and to effectively audit quality and safety.

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

• Ensure that persons providing care and treatment to service users have the qualifications, competence, skills and experience to do so safely.

• 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 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.

• Ensure the practice’s infection control procedures and protocols are suitable 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 an effective system is established to assess, monitor and mitigate the risks arising from undertaking of the regulated activities.
• Ensure audits of various aspects of the service, such as radiography, infection control and dental care records are undertaken at regular intervals to help improve the quality of service. The practice should also check all audits have documented learning points and the resulting improvements can be demonstrated.

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

• Review the protocols and procedures for use of X-ray equipment giving due regard to Guidance Notes for Dental Practitioners on the Safe Use of X-ray Equipment.
• 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.

• Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.
• Establish a system for recording the induction of agency staff.
• Review the storage of dental care records to ensure they are stored securely.
• Review the practice's policies and ensure they are up to date.
• Review its current systems to seek and act on patient feedback.
• Review its audit protocols to ensure audits of various aspects of the service, such as radiography and dental care records are undertaken at regular intervals to help improve the quality of service. Practice should also ensure all audits have documented learning points and the resulting improvements can be demonstrated.

We inspected this service in July 2013 and found the service was not compliant with regulations because treatment plans did not include details of any fees that were payable. At this inspection we found improvements had been made and the service was now compliant. The manager told us that details of any fees payable for treatment were explained to people in advance of the treatment. We found treatment plans included details of any fees payable, and that the plans had been signed by people to show they agreed to the fees and treatment.

People told us that they were treated with respect. One person said the staff were "really lovely." we saw that the lay out of the building enabled people to have confidential discussions. People told us they were happy with the treatment they received. One person said "it's really good. I am really happy with the treatment." We found that the service routinely checked people's medical history. Treatment plans were in place which set out the treatments to be provided. However, people were not provided with a written record of any fees payable, nor did they sign to indicate consent to treatment where fees were payable.

We found that the service had safeguarding procedures in place, and most staff we spoke with had a good understanding of safeguarding issues. People told us they found the service to be clean. We found that systems were in place to prevent the risk of the spread of infection.