We carried out a follow- up inspection of this service on 27 February 2017.

We had undertaken an announced comprehensive inspection of this service on 02 November 2016 as part of our regulatory functions where 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.

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

We revisited the surgery as part of this review and checked whether they had followed their action plan.

You can read the report from our last comprehensive inspection by selecting the 'all reports' link for     Dr Davinderpal S Kooner - Southall Dental Centre on our website at www.cqc.org.uk.

We carried out an announced comprehensive inspection on 02 November 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 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

Dr Davinderpal S Kooner - Southall Dental Centre is located in the London Borough of Ealing and provides NHS and private dental treatment to both adults and children. The premises are on the first floor above retail premises and consist of two treatment rooms and a reception. The practice is open Monday - Friday 9:00am – 6:00pm and alternate Saturdays 9:00am – 1:00pm.

The staff consists of the principal dentist, four associate dentist, a dental nurse, two receptionists and a practice manager.

The principal dentist is registered with the Care Quality Commission (CQC) as an individual ‘registered person’. 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 reviewed 27 CQC comment cards, the NHS Friends and Family test and the practice comments book. Patients were positive about the service. They were complimentary about the friendly and caring attitude of the staff.

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

Our key findings were:

• Patients were involved in their care and treatment planning so they could make informed decisions.

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

• Patients were treated with dignity and respect.

• Patients indicated that they found the team to be efficient, professional, caring and reassuring.
• Patients had good access to appointments, including emergency appointments, which were available on the same day.
• We found the dentists regularly assessed each patient’s gum health and took X-rays at appropriate intervals.

• The practice had not implemented clear procedures for managing comments, concerns or complaints.
• Leadership structures were not clear and there were processes in place for dissemination of information and feedback to staff.

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

• Ensure the practice’s infection control procedures and protocols are suitable taking into account 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’.
• There were appropriate equipment and access to emergency drugs to enable the practice to respond to medical emergencies. Staff knew where equipment was stored.< >The practice did not have effective processes in place to reduce and minimise the risk and spread of infection.Ensure the practice’s sharps handling procedures and protocols are in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.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. The practice should also check that where applicable audits have documented learning points and the resulting improvements can be demonstrated.
• 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 that all 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 waste is segregated and disposed of in accordance with relevant regulations giving due regard to guidance issued in the Health Technical Memorandum 07-01 (HTM 07-01).
• Ensure audit protocols to document learning points are shared with all relevant staff and ensure that the resulting improvements can be demonstrated as part of the audit process.
• Ensure the practice establishes an effective system to assess, monitor and mitigate the various risks arising from undertaking of the regulated activities.

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

• Review the practice's protocols for completion of dental records giving due regard to guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.
• Ensure that a system for identifying, receiving, recording, handling and responding to complaints by patients is established.
• Review the practice’s protocols for recording in the patients’ dental care records or elsewhere the reason for taking an X-ray and quality of the X-ray giving due regard to the Ionising Radiation (Medical Exposure) Regulations (IRMER) 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 storage of dental care records to ensure they are stored securely.
• Review its responsibilities as 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 staff are up to date with their mandatory training and their Continuing Professional Development (CPD).