We undertook a focused inspection of Little London Dental Care on 14 December 2018. 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 remotely by a specialist dental adviser.

We had undertaken a comprehensive inspection of Little London Dental Care on 05 and 08 July 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 in accordance with the relevant regulations 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 Little London Dental Care on our website www.cqc.org.uk.

When one or more of the five questions are 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.

As part of this inspection we asked:

• Is it well-led?

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 breaches we had found at our previous inspections on 05 and 08 July 2018.

Background

Little London Dental Care is in Chichester, West Sussex and provides NHS and private treatment to adults and children.

The practice is accessed via several steps and is situated over three floors. Car parking spaces for blue badge holders are available near the practice which is within a short walk of car parks.

The dental team includes three associate dentists, one dental hygienist, one qualified dental nurse, two trainee dental nurses, four receptionists and a practice manager who is also a qualified dental nurse. The practice has four operational treatment rooms.

The practice is owned by a company 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. At the time of the inspection the practice manager was applying to be the registered manager and this application was underway.

During the inspection we spoke with the two dentists, two trainee dental nurses, three 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:

• Monday to Friday from 8.30am to 5.30pm
• Saturday from 9am to 1pm (one Saturday a month by appointment only)

Our key findings were:

• The practice was providing care and treatment in a safe way to patients
• The practice had implemented effective systems and processes to ensure good governance which can be sustained in the longer term, in accordance with the fundamental standards of care.
• The practice had implemented systems to ensure that persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
• The practice had implemented recruitment procedures to ensure that these were operated effectively and that only fit and proper persons were employed.
• The practice had ensured that specified information was available regarding each person employed.
• The practice had reviewed the practice's protocol and staff awareness of their responsibilities in relation to the Duty of Candour to ensure compliance with The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
• The practice had reviewed staff awareness of the requirements of the Mental Capacity Act 2005 and ensured that all staff are aware of their responsibilities under the Act as it relates to their role.
• The practice had reviewed staff awareness of Gillick competency and ensured all staff are aware of their responsibilities in relation to this.
• The practice had implemented an effective system to monitor and track referrals to ensure that these are dealt with promptly.

We carried out an announced focused inspection on 29 October 2015 to follow up on a previous inspection carried out on 28 April 2015 to ask the practice the following key questions; Are services effective, responsive and well-led?

Our findings were:

Are services effective?

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

Background

CQC inspected the practice on 28 April 2015 and asked the provider to make improvements regarding Regulation 17 HSCA (RA) Regulations 2014 Good governance.

We checked these areas as part of this focused inspection and found this had been resolved.

Little London Dental Care is a general dental practice in Chichester offering both NHS and private dental treatment. The practice is one of many governed by Southern Dental a corporate provider. The practice treats adults and children.

The practice has five dentists, three receptionists and two qualified dental nurses, four trainee dental nurses who are all supported by a practice manager, the provider’s area business manager, and a complaints and compliance manager. The practice has the services of two part time dental hygienists who carry out preventative advice and treatment on prescription from the dentists.

The business manager is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. 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 carried out an announced focused inspection on 29 October 2015 to follow up on the

breaches of regulation found at the last inspection on 28 April 2015. Following the last inspection we asked the provider to take action through a requirement notice for the following regulation; 17 Good governance; and found that the practice was providing effective, responsive and well-led care.

Our key findings were:

• The practice had implemented time management and specified appointment lengths to ensure that patients were not rushed during their appointments and helped to reduce waiting times.
• Completed audit cycles demonstrated that radiographs were of a good diagnostic quality and were below the 10% parameters for unusable images.
• Record card audits had identified strengths and weaknesses and training and support had been implemented as a result. Dental Care records were a more accurate reflection of patient treatment and care and followed current guidance.
• An audit and compliance manager role had been created and fulfilled to oversee all aspects of governance for the Southern Dental practices in the region.
• Complaints were handled and responded to appropriately and in a timely manner which reflected the practice policy.
• Student dental nurses were supported by qualified dental nurses and dentists and could demonstrate a comprehensive knowledge of their job role.
• The practice had implemented a system to follow up and keep track of referrals to other dental and health care professionals.
• All staff had completed Mental Capacity Act training via an online educational tool.
• The practice had a procedure to record, analyse, and mitigate risks across the practice to keep staff, patients and visitors safe.

Little London Dental Care is a general dental practice in Chichester offering both NHS and private dental treatment. The practice treats adults and children.

The premises consists of a waiting area adjacent to the reception area and eight treatment rooms over three floors. There is also a separate decontamination area.

The staff structure of the practice consists of the practice manager, five dentists, three receptionists and five trainee dental nurses. The practice has the services of two part time dental hygienists who carry out preventative advice and treatment on prescription from the dentists.

We spoke with one patient on the day of our inspection and reviewed 14 comment cards that had been completed by patients. Common themes were patients overall were satisfied with the friendly and caring treatment they had received, although three people told us they were unhappy that their dentist changed frequently and two people told us they were unhappy with long waiting times.

We found that this practice was providing safe and caring services in accordance with the relevant regulations. However we found that this practice was not providing effective, responsive and well-led care in accordance with the relevant regulations.

Our key findings were:

• There were clearly defined leadership roles within the practice and staff told us they felt supported and comfortable to raise concerns or make suggestions.

• The practice had effective systems to assess and manage risks to patients for infection prevention and control and the management of medical emergencies.

• Patients told us through comment cards they were treated with kindness and respect by staff.

• Patients were able to make routine and emergency appointments when needed. There were clear instructions for patients regarding out of hours care.

• The practice did not always ensure there was sufficient time to explain fully the care and treatment they were providing in a way patients understood.

• The practice did not have an established effective system for handling and responding to complaints made by patients.

• The practice did not have effective systems in place to assess, monitor and improve the quality and safety of the services provided.

• The practice did not have effective systems in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients, staff and visitors.

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

• Establish an effective system to assess, monitor and improve the quality and safety of the services provided.

• Establish an effective system to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients, staff and visitors.

• Ensure accurate and contemporaneous clinical patient records are always maintained.

You can see full details of the regulations not being met at the end of this report

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

• Ensure all staff are aware of the Mental Capacity Act 2005 and its relevance to obtaining informed consent for dental treatment.

• Ensure the training, learning and development needs of individual staff members, including trainee dental nurses are reviewed at appropriate intervals and an effective process is established for the on-going assessment and supervision of all staff.

• Establish a process for monitoring the referral of patients for dental treatment and specialist procedures to other healthcare professionals which ensures timely access to care and treatment.

• Ensure the practice procedure for acknowledging, recording, investigating and responding to complaints, concerns and suggestions made by patients is fully established and effective.

We spoke with six patients during our visit. The majority were satisfied with the service they had received. One said, “I felt at ease even though I don’t like coming to the dentist”. Another told us, “Really good, really friendly. They’re helpful and it’s a good service”. A number of patients mentioned that any dissatisfaction they had with the practice arose from the fact that they had frequently seen different dentists. They told us that they would appreciate more continuity.

We spoke with the manager, five members of staff and a representative of the provider. They all spoke positively about the practice. Staff told us that it was busy but that they felt involved and able to make suggestions.

We found that the practice was welcoming. People were offered choices about the treatment that they received and were cared for in a safe and clean environment. There was an effective system in place to monitor the quality of service provision and to respond to any new needs or issues.

We carried out this unannounced inspection on 05 and 11 July 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

Little London Dental Care is in Chichester, West Sussex and provides NHS and private treatment to adults and children.

The practice is accessed via several steps and is situated over three floors. Car parking spaces for blue badge holders are available near the practice which is within a short walk of car parks.

The dental team includes three associate dentists, one dental hygienist, two trainee dental nurses, four receptionists and a practice manager. The practice has eight treatment rooms.

The practice is owned by a company 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. At the time of the inspection the registered manager was no longer working at the practice having left three months prior to the inspection.

During the inspection we spoke with three dentists, two trainee dental nurses, one qualified nurse and one trainee dental nurse working temporarily at the practice. We also spoke with all the receptionists, the practice manager, and the compliance manager and the regional support manager for the company. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

• Monday to Friday from 8.30am to 5.30pm

Our key findings were:

• The clinical staff provided patients’ care and treatment in line with current guidelines.
• The practice staff had information governance arrangements.
• Staff took care to protect patients’ privacy and personal information.
• The practice was providing preventive care and supporting patients to ensure better oral health.
• The practice premises were visibly dirty and poorly maintained.
• The practice had ineffective infection control procedures which did not reflect published guidance.
• Staff knew how to deal with emergencies though medicines and life-saving equipment were not available as described in recognised guidance.
• The practice had ineffective systems to help them manage risk.
• The practice had some safeguarding processes but not all staff knew their responsibilities for safeguarding vulnerable adults and children.
• The practice had ineffective staff recruitment procedures.
• The appointment system was being reviewed to ensure it met patients’ needs.
• The practice had ineffective leadership with limited systems in place to encourage continuous improvement.
• The practice asked staff and patients for feedback about the services they provided, although the results of patient feedback were not analysed for the purpose of continually evaluating and improving services.
• The practice staff maintained a log of complaints although systems in place to deal with these were used inconsistently.

These findings were brought to the attention of the compliance manager for the company who initiated immediate action to mitigate the urgent risks.

We identified regulations the provider was not complying with. They must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
• Ensure specified information is available regarding each person employed.

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

• Review the practice's protocol and staff awareness of their responsibilities in relation to 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 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.
• Review staff awareness of Gillick competency and ensure all staff are aware of their responsibilities in relation to this.
• Review the practice’s systems to monitor and track referrals to ensure that these are dealt with promptly.