We carried out a follow- up inspection of this service on 19 January 2017.

We had undertaken an announced comprehensive inspection of this service on 02 June 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 one of the five questions we ask about services: is the service 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 Kilburn Corner Dental on our website at www.cqc.org.uk.

We carried out an announced comprehensive inspection on 02 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 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

Kilburn Corner Dental is located in the London Borough of Brent and provides mainly NHS dental treatment to both adults and children. The premises are on the first and second floor and consist of three treatment rooms, a reception area and a dedicated decontamination room. The practice is open Monday to Friday 9:00am – 5:30pm.

The staff consists of one principal dentist, two associate dentists and four dental nurses, two of whom are also receptionist.

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.

We reviewed 42 CQC comment cards and the NHS Friends and Family test comment cards. 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:

• There were appropriate equipment and access to emergency drugs to enable the practice to respond to medical emergencies. Staff knew where equipment was stored.
• Patients had good access to appointments including emergency appointments.
• We observed staff to be caring, friendly, reassuring and welcoming to patients.
• Patients indicated that they found the team to be efficient, professional, caring and reassuring.

• The practice had effective safeguarding processes in place and staff understood their responsibilities for safeguarding adults and child protection.
• We found the dentists regularly assessed each patient’s gum health and took X-rays at appropriate intervals.
• There was a lack of effective arrangements in place to meet the Control of Substances Hazardous to Health 2002 (COSHH) Regulations.
• The practice infection control procedures required improvement in line with current national guidance.
• Staff did not receive appropriate support and appraisal as is necessary to enable them to carry out their duties.
• There was a lack of an effective system to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients, staff and visitors.
• Governance arrangements in place were not effective to facilitate the smooth running of the service and there was no evidence of audits being used for continuous improvements.

We identified regulations that were not being met and the provider 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 that the practice implements robust procedures and processes that make sure that people are protected.
• 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 the practice’s sharps handling procedures and protocols are in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
• Ensure that the practice is in compliance with its legal obligations under Ionising Radiation Regulations (IRR) 99 and Ionising Radiation (Medical Exposure) Regulation (IRMER) 2000.
• 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 audits of various aspects of the service, such as radiography, infection control and dental care records are undertaken at regular intervals to help improve the quality of service. The practice should also check all audits have documented learning points and the resulting improvements can be demonstrated.
• Ensure the practice establishes an effective system to assess, monitor and mitigate the various risks arising from undertaking of the regulated activities.
• Ensure the practice establishes a 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.
• Ensure the practice undertakes a Legionella risk assessment and implements the required actions 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.

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

• Review availability of 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 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 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 (IRMER) 2000.

• Review the storage of dental care records to ensure they are stored securely.

• Review its complaint handling procedures and establish an accessible system for identifying, receiving, recording, handling and responding to complaints by patients.

• Review the storage of records related to people employed and the management of regulated activities giving due regard to current legislation and guidance.
• Review the practice protocol for a Legionella risk assessment and implement the required actions 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 practice staff were friendly welcoming and informative. The practice was clean and well maintained.

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

The dentist described the decontamination process to us and provided evidence to show the correct checks were carried out on the decontamination equipment. All the staff had received training in infection control.

We spoke to five patients who told us the staff were helpful and listened to you. They were given appropriate information regarding their treatment options and cost as well as information about how to improve their dental health. One patient told us "When I first attended I was phobic of dentists but now I am a lot more comfortable about attending the dentist".

The patients had consented to treatment and the staff were well trained and caring.

We spoke with patients and reviewed feedback from patient questionnaires. Patients told us that they liked using the dental clinic and felt the dentists clearly explained all their treatments. Patients reported that staff were friendly and helpful and they felt they were given enough time and information to make decisions about their dental care. They told us that they are involved in their dental care and respected by staff.

We observed staff interacting positively with people that used the service. People were seen in private consultation rooms. The environment itself was clean and well maintained.