We undertook a focused inspection of Firs Dental Surgery on 14 February 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 Firs Dental Surgery on 16 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 well led care and was in breach of regulation 17 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 Firs dental practice on our website www.cqc.org.uk.

As part of this inspection we asked:

• 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 (requirement notice only). We then inspect again after a reasonable interval, focusing on the area(s) where improvement was required.

Our findings were:

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.

Background

Firs dental surgery is in Caterham and provides NHS and private treatment for adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces, including, blue badge holders, are available near the practice.

The dental team includes three dentists, two dental nurses, one trainee dental nurse one dental hygienist and one receptionist. The practice has three treatment rooms.

The practice is owned by a partnership and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers 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 registered manager at Firs dental practice is the principal dentist. A registered manager is legally responsible for the delivery of services for which the practice is registered.

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

The practice is open: from Monday to Friday 08.30-17.00

We carried out this announced inspection on 16 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 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

Firs dental practice is in Caterham and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice.

The dental team includes 3 dentists, 2 dental nurses, 1 locum dental hygienist and 2 receptionists. The practice has 3 treatment rooms.

The practice is owned by a partnership and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers 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 registered manager at Firs dental practice was the principal dentist and registered manager

On the day of inspection, we collected 8 CQC comment cards filled in by patients and spoke with 2 other patients.

During the inspection we spoke with 2 dentists, 2 dental nurses and 1 receptionists 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 Monday to Friday 08.30-17.00

Our key findings were:

• The practice appeared clean and well maintained.
• The practice staff had infection control procedures which reflected published guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
• The practice had some systems to help them manage risk.
• The practice staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
• The practice had thorough staff recruitment procedures.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• The practice was providing preventive care and supporting patients to ensure better oral health.
• The appointment system met patients’ needs.
• The practice had effective leadership and culture of continuous improvement.
• Staff felt involved and supported and worked well as a team.
• The practice asked staff and patients for feedback about the services they provided.
• The practice staff dealt with complaints positively and efficiently.
• The practice staff had some suitable information governance arrangements.

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

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulation/s the provider was/is not meeting are at the end of this report.

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

• Review the suitability of the premises and ensure all areas are fit for the purpose for which they are being used.
• Review the practice’s protocols for recording in the patients’ dental care records or elsewhere the reason for taking X-rays, a report on the findings and the quality of the image in compliance with Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment.
• Review the practice’s protocols for ensuring that all clinical staff have adequate immunity for vaccine preventable infectious diseases.
• Review the practice's risk management systems for monitoring and mitigating the various risks arising from the undertaking of the regulated activities.
• Review the practice’s protocols to ensure audits of radiography and infection prevention and control are undertaken at regular intervals to improve the quality of the service. Practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.