We carried out a focused inspection of John Dineen Dental Surgery on 21 September 2017.

The inspection was led by a CQC inspector who was supported by a specialist dental adviser.

We carried out the inspection to follow up concerns we originally identified during a comprehensive inspection at this practice on 8 June 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions.

At a comprehensive inspection we always ask the following five questions to get to the heart of patients’ experiences of care and treatment:

• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well-led?

When one or more of the five questions is 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.

At the previous comprehensive inspection we found the registered provider was providing safe, effective, caring and responsive care in accordance with relevant regulations. We judged the practice was not providing well-led care in accordance with 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 John Dineen Dental Surgery on our website www.cqc.org.uk.

We also reviewed the key questions of safe and effective as we had made recommendations for the provider relating to these key questions. We noted that improvements had been made.

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 to put right the shortfalls and deal with the regulatory breach we found at our inspection on 8 June 2017.

We carried out this announced inspection on 8 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 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

John Dineen Dental Surgery is in Leyton in the London Borough of Waltham Forest and provides NHS and private treatment to patients of all ages.

The dental practice is located on the ground of an adapted residential property and there is level access for people who use wheelchairs and pushchairs.

The dental team includes the principal dentist and one associate dentist, five dental nurses and a practice manager. Reception duties are carried out by the practice manager and other staff on a rota basis. The practice has three treatment rooms which are located on the ground floor.

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

During the inspection we spoke with two dentists, 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 between 8am and 5.30pm on Mondays to Fridays (excluding Bank Holidays) and between 8am and 1pm on Saturdays.

Our key findings were:

• The practice was clean and well maintained.
• The practice had infection control procedures which reflected published guidance and these were regularly audited to ensure their effectiveness.
• The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
• The practice had thorough staff recruitment procedures which were followed when employing new staff.

• 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 appointment system met patients’ needs including patients who required emergency dental treatment.
• 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 had systems to deal with complaints positively and efficiently.
• Staff were trained in basic life support and knew how to deal with emergencies. However some medicines and life-saving equipment as per current national guidelines were not available. The practice responded immediately to procure these pieces of equipment and medicines.
• The practice had some systems to help them manage risks and monitor quality though improvements were required in the overall governance and risk management structure of the practice. .

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.

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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 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 training, learning and development needs of individual staff members at appropriate intervals and ensure an effective process is established for the on-going assessment, supervision and appraisal of all staff.

• 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.
• 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 ensuring compliance with the Ionising Radiation (Medical Exposure) Regulations (IRMER) 2000.

• 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 the practice’s audit protocols to ensure audits of various aspects of the service, such as radiography are undertaken at regular intervals to help improve the quality of service. Practice should also ensure, that where appropriate audits have documented learning points and the resulting improvements can be demonstrated.

• Review the use of risk assessments to monitor and mitigate the various risks arising from undertaking of the regulated activities.

We found that people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. The provider had ensured that arrangements were in place to support supervision and appraisal of staff. A programme of training was in place to enable staff to carry out their responsibilities to an appropriate standard.

Staff records had been updated and were in order. The service had not recruited any new staff so induction records were not on file. Files did contain details of staff previous employment history by way of a curriculum vitae, criminal record checks, indemnity certificates, immunisation and evidence of continuing professional development.

We spoke to three patients who used the service during our visit.

Patients told us that they were given treatment plans which included the cost of their treatment and the three patients we spoke to were satisfied with the care and treatment they had received. Two of the patients told us that they had been fully involved in the discussions about their treatment. Patients said that the practice is very clean and that the dentist always wore gloves and a mask. Patients told us that it was easy to make an appointment and that they will always see you in an emergency, but that sometimes they had to wait or the next appointment.

There were effective systems in place to reduce the risk of infection. The decontamination of instruments took place in a designated recently furbished separate room.

We found that staff records were not accurate and adequately maintained. Staff training records were not available and there were no systems in place to support staff carry out their roles effectively.