We undertook a focused inspection of Dental Surgery - Stonegate on 13 August 2018. 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 on 23 November 2017 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 and well led care in accordance with the relevant regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We undertook a focused inspection on 23 April 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 in accordance with the relevant regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can read our reports of the inspections by selecting the 'all reports' link for Dental Surgery - Stonegate on our website www.cqc.org.uk.

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.

As part of this inspection we asked:

• Is it safe?

• Is it effective?

• Is it well-led?

Our findings were:

Are services safe?

We found this practice was providing safe care in accordance with the relevant regulations.

The provider had made improvements in relation to the regulatory breaches we found at our inspection on 23 April 2018.

Are services effective?

We found this practice was providing effective care in accordance with the relevant regulations.

Areas for improvement previously identified within the effectiveness key question on the 23 April 2018 were much improved. Further progress could be made in relation to awareness of the Mental Capacity Act 2005 and details can be found in the main body of the report under consent to care and treatment.

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 breaches we found at our inspection on 23 April 2018.

Background

Dental Surgery - Stonegate is in York and provides NHS and private treatment to adults and children.

Due to the practice being located on the first floor, patients with mobility requirements are referred to a local practice that can help with access more easily.

The dental team includes the principal dentist, four dental nurses (one of whom is a trainee dental nurse), a short-term practice manager and a practice cleaner.

The practice has one surgery, a decontamination room for sterilising dental instruments, a staff room/kitchen and a general office.

The practice is owned by an individual who is the principal dentist. 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 dentist, the practice manager 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 – Friday 9am to 12 pm & 2pm to 5pm

Our key findings were:

• The practice appeared clean and well maintained.
• The provider had infection control procedures which reflected published guidance.
• The process to identify, record and respond to a significant event was much improved.
• Staff were confident they knew how to deal with medical emergencies. Emergency medicines and life-saving equipment reflected up to date guidance.
• The practice had improved systems to help them manage risk to patients and staff.
• Fire safety management systems were embedded and the practice was compliant with fire regulations.
• The practice was registered to receive medical device alerts from Medicines and Healthcare Products Regulatory Authority (MHRA).
• Clinical waste was prepared for disposal in line with recognised guidance.
• Awareness of safeguarding procedures had improved but the provider’s knowledge of the reporting processes to follow remained limited.
• The provider had thorough staff recruitment procedures.
• The provider’s awareness of acquiring appropriate consent in relation to the Mental Capacity Act 2005 remained limited.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Leadership and management had improved in all areas and staff felt supported.

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

• Review the practice’s safeguarding processes to ensure reporting procedures are fully embedded.
• 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 staff awareness of the requirements of the Mental Capacity Act 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.

We carried out an announced follow-up inspection at Dental Surgery - Stonegate on 23 April 2018.

We had undertaken an announced comprehensive inspection of this service on the 23 November 2017 as part of our regulatory functions where breaches of legal requirements were found.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to the breaches. This report only covers our findings in relation to those requirements. We checked whether they had followed their action plan to confirm that they now met the legal requirements.

We reviewed the practice against three of the five questions we ask about services: are the services safe, effective and well led? You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dental Surgery - Stonegate on our website at www.cqc.org.uk.

We revisited Dental Surgery - Stonegate as part of this review and checked whether they now met the legal requirements. We carried out this announced inspection on 23 April 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 second CQC inspector and two specialist dental advisers.

Is it safe?

Is it Effective?

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 well-led?

We found that this practice was not providing well-led care in accordance with the relevant regulations.

Background

Dental Surgery - Stonegate is in York and provides NHS and private treatment to adults and children.

Due to the practice being located on the first floor, patients with mobility requirements are referred to a local practice that can help with access more easily.

The dental team includes the principal dentist, four dental nurses (two of whom are locums and one is a trainee) and a short-term practice manager.

The practice has one surgery, a decontamination room for sterilising dental instruments, a staff room/kitchen and a general office.

The practice is owned by an individual who is the principal dentist. 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 dentist, the practice manager 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 – Friday 9am to 12 pm & 2pm to 5pm

Our key findings were:

• Environmental cleaning of the practice was now carried out in line with recommended guidance.
• Infection control procedures were much improved and mostly reflected current guidance. Improvements could be made to ensure the practice was fully in line with guidance.
• Staff awareness of the process to identify, record and respond to a significant event remained limited.
• Staff were now confident they knew how to deal with medical emergencies. Emergency medicines and life-saving equipment reflected up to date guidance.
• Staff knowledge of systems to help them manage risk was limited.
• Fire safety management systems were improved. Further improvements could be made to ensure the process is fully embedded.
• The practice was now registered to receive medical device alerts from Medicines and Healthcare Products Regulatory Authority (MHRA).
• A process for the disposal of items identified under Control of Substances Hazardous to Health was in place.
• Clinical waste was not being prepared for disposal in line with recognised guidance.
• Staff awareness of safeguarding procedures had improved but knowledge of the processes to follow was not fully embedded at all levels.
• Awareness of the appropriate staff recruitment process to follow had improved but was not embedded.
• Clinical staff provided patients’ care and treatment mostly in line with current guidelines but improvements could be made.
• Some areas of leadership had improved and staff felt supported although further action was necessary to ensure leadership was effective at all levels.
• Areas of concern relating to patients privacy and confidentiality had been addressed.

We carried out this announced inspection on 23 November 2017 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.

We told the NHS England area team and Healthwatch that we were inspecting the practice. We did not receive any information of concern from them.

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

Dental Surgery - Stonegate is in York and provides NHS and private treatment to adults and children.

Due to the practice being located on the first and second floor, patients with mobility requirements are referred to a local practice that can help with access more easily.

The dental team includes one dentist, three dental nurses, and a receptionist.

The practice has one surgery a decontamination room for sterilising dental instruments, a staff room/kitchen and a general office

The practice is owned by an individual who is the principal dentist. 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 collected 79 CQC comment cards filled in by patients and spoke with three other patients. This information gave us a positive view of the practice.

During the inspection we spoke with one 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 – Friday 9am – 12 pm & 2pm – 5pm

Our key findings were:

• Environmental cleaning of the practice was not carried out in line with recommended guidance.
• The practice had infection control procedures in place which reflected out of date guidance.
• Staff were not confident they knew how to deal with medical emergencies. Not all appropriate emergency medicines and life-saving equipment were available.
• The practice did not have effective systems to help them manage risk. There were no fire safety management systems in place.
• The practice was not registered to receive medical device alerts from Medicines and Healthcare Products Regulatory Authority (MHRA).
• The disposal process and security of clinical waste and items identified under Control of Substances Hazardous to Health was not always adhered to.
• The practice did not have effective safeguarding processes and staff were not fully aware of their responsibilities for safeguarding adults and children.
• The appointment system met patients’ needs.
• The practice did not have thorough staff recruitment procedures.
• The clinical staff provided patients’ care and treatment mostly in line with current guidelines but improvements could be made.
• Staff treated patients with dignity and respect. We found areas of concern relating to patients privacy and confidentiality.
• The practice did not have effective leadership. Staff were involved but did not feel supported.
• The practice asked staff and patients for feedback about the services they provided.
• The practice had a complaints process but improvements could be made.

We identified regulations the provider was not meeting. 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.

Full details of the regulations the provider was 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 for the use of rubber dam for root canal treatment giving due regard to guidelines issued by the British Endodontic Society.
• Review the practice’s testing protocols for equipment used for cleaning used dental instruments taking into account guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.
• Review the practice protocols and procedures taking into account guidelines issued by the National Institute for Health and Care Excellence (NICE), the Department of Health publication ‘Delivering better oral health: an evidence-based toolkit for prevention’, the Faculty of General Dental Practice regarding clinical examinations and record keeping, the British Society of Periodontology and ensure the practice is in compliance with the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2000 in relation to recording in the patient’s dental care records.
• Review the storage of archived dental care record to ensure they are protected from environmental and fire risks.
• Review the practice complaint handling procedures and establish an accessible system for patients. Make sure a process is in place for identifying, receiving, recording, handling and responding to complaints by service users.

We carried out a follow- up inspection at the Dental Surgery – Stonegate on the 4 October 2016.

We had undertaken an announced comprehensive inspection of this service on the 31 May 2016 as part of our regulatory functions where breaches of legal requirements were found.

After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to each of the breaches. This report only covers our findings in relation to those requirements.

We reviewed the practice against three of the five questions we ask about services: is the service safe, effective and well-led? You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dental Surgery – Stonegate on our website at www.cqc.org.uk.

We revisited the Dental Surgery – Stonegate as part of this review and checked whether they had followed their action plan and to confirm that they now met the legal requirements.

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 well-led?

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

Background

The Dental Surgery, Stonegate is situated in the centre of York, North Yorkshire close to public transport links. The practice has two treatment rooms, one on the first floor and a decommissioned surgery on the second floor which now acts as a decontamination area. There is a waiting area and a dark room for processing X-rays. Staff facilities were located on the first floor with offices located on the second floor.

Due to the practice being located on the first and second floor, patients with mobility requirements are referred to a local practice that can help with access more easily.

There is one Dentist, a receptionist and two dental nurses.

The practice is open:

Monday – Friday 09:00 – 12:00 & 14:00 – 17:00.

The principal dentist is registered with the Care Quality Commission (CQC) as an individual. 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:

• There were sufficient numbers of suitably qualified staff to meet the needs of patients.
• The practice had systems in place to assess and manage risks to patients and staff including infection prevention and control, health and safety and the management of medical emergencies.
• Staff had received safeguarding training, knew how to recognise signs of abuse and how to report it. They had very good systems in place to work closely and share information with the local safeguarding team.
• There were sufficient numbers of suitably qualified staff to meet the needs of patients.
• Patients were treated with dignity and respect and confidentiality was maintained.
• The appointment system met patients’ needs.

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

• Review the checks of medicines, medical emergency 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.

• 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 safeguarding policy and staff training: ensuring it covers both children and adults and all staff are trained to an appropriate level for their role and aware of their responsibilities.

• Review the practice’s protocols for the use of rubber dam for root canal treatment giving due regard to guidelines issued by the British Endodontic Society.

• Review that the practice undertakes a Legionella risk assessment, 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’ the HSE Legionnaires’ disease. Approved Code of Practice and guidance on regulations L8.

• Review the practice's recruitment policy and procedures to ensure character references for new staff as well as proof of identification and DBS checks are requested and recorded suitably.

• Review the practice protocols and adopt an individual risk based approach to patient recalls giving due regard to National Institute for Health and Care Excellence (NICE) guidelines.

• Review the practice’s protocols and procedures for promoting the maintenance of good oral health giving due regard to guidelines issued by the Department of Health publication ‘Delivering better oral health: an evidence-based toolkit for prevention’.

We carried out an announced comprehensive inspection on 31 May 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

The Dental Surgery, Stonegate is situated in the centre of York, North Yorkshire close to public transport links. The practice has two treatment rooms, one on the first floor and a decommissioned surgery on the second floor which now acts as a decontamination area. There is a waiting area and a dark room for processing radiographs. Staff facilities were located on the first floor with offices located on the second floor.

Due to the practice being located on the first and second floor, patients with mobility requirements are referred to a local practice that can help with access more easily.

There is one Dentist, a receptionist and two dental nurses.

The practice is open:

Monday – Friday 09:00 – 12:00 & 14:00 – 17:00.

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.

On the day of inspection we received 23 CQC comment cards providing feedback and spoke to three patients. The patients who provided feedback were very positive about the care and attention to treatment they received at the practice. They told us they were involved in all aspects of their care and found the staff to be sensitive, friendly, caring and informative and they were treated with dignity and respect in a clean and tidy environment.

Our key findings were:

• There were sufficient numbers of suitably qualified staff to meet the needs of patients.
• The practice did not have access to an automated external defibrillator and the medical oxygen cylinder available on the premises had no supporting evidence that it had ever been serviced or that the oxygen was in date. Staff had not been trained to manage medical emergencies.
• Staff had not received safeguarding training; however they knew how to recognise signs of abuse but not how or who to report it to.
• Patients were treated with dignity and respect.
• The practice did not undertake appropriate pre-employment checks for staff.
• There was a complaints system in place. Staff recorded complaints and cascaded learning to staff.
• Governance arrangements were in not place for the smooth running of the practice; the practice did not have a structured plan in place to audit quality and safety including infection control, radiographs and patient care records.
• The practice sought feedback from staff and patients about the services.
• The practice did not have a structured plan in place to audit quality and safety of services provided. The policies and procedures were not localised to the practice or updated in line with current legislation and guidance.
• The practice staff worked as a team; however they lacked support for undertaking their roles and with professional development.

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

• Ensure protocols for the availability and checks of all medicines and equipment to manage medical emergencies is implemented, 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.
• Ensure staff are up to date with their mandatory training and their Continuing Professional Development (CPD).
• Ensure that all staff had undertaken relevant training, to an appropriate level, in safeguarding of children and vulnerable adults. Ensure that systems and processes are established and operated effectively to safeguard patients from abuse and 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.
• Ensure the practice undertakes a Legionella risk assessment, 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’ the HSE Legionnaires’ disease. Approved Code of Practice and guidance on regulations L8.
• Ensure COSHH risk assessments are implemented for all materials used within the practice. Review the practice responsibility in regards to the Control of Substance 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 of and handling of these substances.
• Ensure the practice implements a protocol for X-ray audits to ensure they are carried out annually and they are carried out in line with the National Radiological Protection Board (NRPB) guidelines.
• Ensure that the practice is compliant with its legal obligations under Ionising Radiation Regulations (IRR) 99 and Ionising Radiation (Medical Exposure) Regulation (IRMER) 2000. Ensure local rules are available and a nominated RPA is in place.
• 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 pressure vessels are serviced and certificated to ensure safe care of equipment in line with the Pressure Systems Safety Regulations 2000 and review the practice protocol for reviewing the PAT testing certificates.

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

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

• 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 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 system for the recording, investigating and reviewing incidents or significant events with a view to preventing further occurrences and, ensuring that improvements are made as a result.
• Review dental care records are maintained appropriately giving due regard to guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping. Adopt an individual risk based approach to patient recalls having regard to National Institute for Health and Care Excellence (NICE) guidelines
• Review the practice’s protocols for the use of rubber dam for root canal treatment giving due regard to guidelines issued by the British Endodontic Society.
• Review the practice’s protocols and procedures for promoting the maintenance of good oral health giving due regard to guidelines issued by the Department of Health publication ‘delivering better oral health: an evidence-based toolkit for prevention’.

The people we spoke to were very positive about the care and service they received at the practice.