We carried out a follow-up inspection at Hayes Croft Dental Surgery on the 9 August 2017.

We had undertaken an announced comprehensive inspection of this service on the 19 June 2017 as part of our regulatory functions where a breach of legal requirements was found.

After the comprehensive inspection, the principal dentist 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 that requirement.

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

We revisited Hayes Croft Dental Surgery as part of this review and checked whether they had followed their action plan and to confirm that they now met the legal requirements. We carried out this announced inspection on 9 August 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.

• Is it well-led?

This question forms the framework for the areas we look at during the inspection.

Our findings were:

Are services well-led?

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

Background

Hayes Croft Dental Surgery is in Barnsley and provides NHS treatment to patients of all ages.

Access into the practice is via a set of steps. The treatment room and main waiting areas are on the first floor. Alternative arrangements are available for patients with limited mobility. Car parking spaces are available near the practice.

The dental team includes one dentist, two dental nurses and a practice manager. The practice has one treatment room.

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 one dentist, two dental nurses and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday 8.30am – 6.30pm

Tuesday, Wednesday, Thursday 8.30am – 5.00pm

Friday 8.30am – 2.00pm

Our key findings were:

• The practice was clean and well maintained.
• The practice 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 systems to help them manage risk.
• 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 had effective leadership. Staff felt involved and supported and worked well as a team.
• The practice asked staff and patients for feedback about the services they provided.

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

Review the practice’s current infection control audit with all staff and implement change where possible taking into account actions which cannot be immediately implemented by annotating a future date for review.  

We carried out this announced inspection on 19 June 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. They provided information which we took into account.

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

Heyes Croft Dental Surgery is in Barnsley and provides NHS treatment to patients of all ages.

Access into the practice is via a set of steps from the pavement. The treatment room and main waiting areas are on the first floor. Alternative arrangements are available for patients with limited mobility. Car parking spaces are available near the practice.

The dental team includes one dentist, two dental nurses and a practice manager. The practice has one treatment room.

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 collected 60 CQC comment cards filled in by patients and spoke with two other patients. This information gave us a positive view of the practice.

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

The practice is open:

Monday 8.30am – 6.30pm

Tuesday, Wednesday, Thursday 8.30am – 5.00pm

Friday 8.30am – 2.00pm

Our key findings were:

• 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.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available but some processes could be improved.
• The practice had some systems to help them manage risk but improvements could be made.
• The practice infection control procedures did not reflect current guidance.
• The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
• The practice had a policy in place for staff recruitment.
• The appointment system took account of patients’ needs.
• Staff felt involved and supported and worked well as a team.
• Management processes and leadership could be improved.
• The practice asked staff and patients for feedback about the services they provided.
• The practice had processes in place to deal with complaints positively and efficiently.
• The practice was generally clean and suitably maintained. Some areas required additional attention.

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

• 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 various risks arising from undertaking of the regulated activities. For example, systems involving fire, sharps and control of substances hazardous to health (COSHH).

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 system for 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 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 availability of medicines and equipment to manage medical emergencies taking into account guidelines issued by the British National Formulary, the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.
• 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 protocols for the use of rubber dam for root canal treatment taking into account guidelines issued by the British Endodontic Society.
• 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 the storage of dental care records to ensure they are stored securely.
• Review the practice's protocol and staff awareness of their responsibilities under the Duty of candour to ensure compliance with The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
• 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.

We spoke privately with four people who were attending the practice for check ups or treatment. All four people told us that they were "very pleased" and "more than satisfied" with all aspects of the service. They told us that staff were "very friendly" and "professional". People told us they had "no grounds for complaint". Everyone commented on the cleanliness of the practice. They said they regularly saw staff making sure that the surgery was clean, tidy and hygienic.