We undertook a focused inspection of Mr Gavin Maw – Houghton-le-Spring dental practice on 7 August 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 with remote access to a specialist dental adviser.

We undertook a comprehensive inspection of Mr Gavin Maw – Houghton-le-Spring on 8 May 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 Mr Gavin Maw – Houghton-le-Spring dental practice 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 area 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 breach we found at our inspection on 8 May 2018.

Background

Gavin Maw’s dental practice is in Houghton-le-Spring and provides NHS and private treatment to adults and children.

The practice is situated on the ground floor of a building. The entrance to the practice has a small step. A portable ramp was available for people who use wheelchairs and those with pushchairs.

Limited car parking spaces are available outside the practice.

The dental team includes the principal dentist, two associate dentists, the practice manager and five dental nurses who also perform reception duties. The practice has two treatment rooms.

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 the principal 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 and Wednesday 8.30am to 6pm

Tuesday 8.30am to 7pm

Thursday 8.30am to 5pm

Friday 8.30am to 4pm.

Our key findings were:

• The provider had systems to help them manage risk. A fire risk assessment of the premises had been carried out since our comprehensive inspection. Appropriate fire detection and fire-fighting equipment were in place with regular checks for these. All hazardous materials were risk assessed in line with the Control of Substances Hazardous to Health Regulations 2002.
• Infection prevention and control systems were reviewed and amended to comply with national guidance. This included systems to segregate and correctly dispose of waste, maintain and service sterilisation equipment and environmental cleaning processes.
• Infection prevention and control audit processes were effective.
• Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
• The principal dentist had assessed the needs of all population groups in line with the Equality Act 2010.
• Policies were dated, reviewed and signed by all members of staff to indicate they had been read and understood.
• The inspection frequency of the practice’s pressure vessels was reviewed and an inspection of the compressor had been completed since our comprehensive inspection.
• The practice's protocols for medicines management were amended to ensure all medicines were stored safely and securely.

We carried out this announced inspection on 08 May 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

Gavin Maw’s dental practice is in Houghton-le-Spring and provides NHS and private treatment to patients of all ages.

The practice is situated on the ground floor of a building. The upper floor is currently unoccupied. The entrance to the practice has a small step in front and we were told people who use wheelchairs and those with pushchairs are provided with assistance to get over the step by staff or by accompanying people.

Limited car parking spaces are available outside the practice.

The dental team includes the principal dentist, two associate dentists, the practice manager and five qualified dental nurses who also perform reception duties. The practice has two treatment rooms.

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 18 CQC comment cards filled in by patients.

During the inspection we spoke with the principal dentist, an associate dentist, three 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 and Wednesday 8.30am to 6pm

Tuesday 8.30am to 7pm

Thursday 8.30am to 5pm

Friday 8.30am to 4pm.

Our key findings were:

• The practice appeared clean and well maintained.
• The practice 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.
• 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 dealt with complaints positively and efficiently.
• The practice had suitable information governance arrangements.
• Improvements were needed to the leadership of the practice.
• The practice had infection control procedures which did not fully reflect published guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were not available as in recommended national guidance.
• The practice had limited systems to help them manage risk.

We identified regulation 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 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 written scheme of examination for the practice’s pressure vessels to ensure the inspection frequency is in accordance to that advised.

• Review the practice's protocols for medicines management and ensure all medicines are stored safely and securely.

We spoke with three people who used the service to find out their opinions on the treatment provided at the practice. Because the practice was busy, we spoke to one person on the day of the inspection and we contacted two people by telephone.

They explained their dignity was maintained and their privacy protected. They said the practice was always clean and the staff were professional and friendly. One person told us “It is very clean I have never had any problems” and "The dentist is very good". Another person commented "They are excellent on all levels" and "I am disabled and they have been very helpful, they have given me appointments at times of the day when it is easier for me to park my car".