We carried out an announced comprehensive inspection of this practice on 24 June 2015. Breaches of legal requirements were found. The practice was visited again on 22 July 2015 to confirm that improvements were underway. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to the breaches.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for N Bloom & Associates - Bridlington Road on our website at www.cqc.org.uk

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 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

N Bloom & Associates - Bridlington Road is a dental practice in the Oxhey area of Watford, Hertfordshire.

The practice has three treatment rooms, a waiting area, and a multi-purpose room which houses X-ray machines and an autoclave (to sterilise dental instruments). It provides NHS and private treatment to adults and children.

The CQC inspected the practice on 24 June 2015 and again on 22 July 2015 and asked the provider to make improvements regarding safeguarding of vulnerable adults and children, infection control, safe use of X-rays, recognising and mitigating risk, supervision and training of staff, clinical audit, underperformance process and patient and staff feedback.

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.

Our key findings were:

• The practice met the essential standards in infection control and cleanliness documented in the Department of Health's: ‘Health Technical Memorandum 01-05 (HTM 01-05).

• All X-ray equipment had been serviced and tested in line with Ionising Radiation Regulations (IRR) 99 and Ionising Radiation (Medical Exposure) Regulation (IR(ME)R) 2000.

• The practice had policies in place to aid the smooth running of the service, these were readily available for staff to reference, and in some cases were displayed in staff areas of the practice.

• Staff recruitment procedures met the requirements of Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

• Clinical and non- clinical audit was used to highlight areas of practice that could be improved.

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

• 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 (IR(ME)R) 2000.

We carried out an announced comprehensive inspection on 24 June 2015. At this inspection we identified a number of breaches of the regulations. Some of the concerns affected patient safety and there were some procedural issues. As a result of these findings we asked the provider to assure us that patient safety issues had been dealt with immediately and that they were working towards making improvements in the other areas of concern.

We then visited the practice again on 22 July 2015 after being advised that the safety issues had been actioned. We attended to check that these had taken place and that patients were safe. We also looked at what other progress was being made in relation to the concerns we found at our first visit.

We 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 not providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this practice was not 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 not 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

The practice has a lead dentist who employs two other dentists that work full time. The dentists are supported by three dental nurses a practice manager and reception staff that work a variety of hours. The practice has three surgeries, a decontamination room and an X-ray suite.

The practice provides primary dental services to mainly NHS patients but also provides private care. The practice is open Monday to Thursday between the hours of 8.30am and 5.30pm and Fridays between the hours of 8.30am and 2pm. They are closed at weekends.

We were unable to speak with patients on the day of the inspection but did review CQC comment cards left for patients to complete prior to the inspection. There were 11 completed cards. The comments left by patients indicated that the majority of those patients were happy with the services provided by the dentists and the reception staff, including the way they supported nervous patients. We received one negative comment about the quality of the dentistry.

The lead dentist is the responsible individual. A responsible individual 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.

Our key findings at the first inspection at the practice were:

• Staff felt supported and were encouraged to develop themselves through training.
• Patients were treated with dignity and respect and they said staff were kind and supportive.
• Dental staff followed published dental guidance when undertaking consultations and explained care and treatment options to patients and involved them in decisions.
• There were sufficient numbers of staff working at the practice.
• Significant events were not being identified, recorded and analysed effectively or learning identified and cascaded to staff.
• Where mistakes had been made patients were not given appropriate explanations about the outcome of any investigation and there was a lack of clinical input and oversight by the provider.
• Some staff had not received safeguarding and whistleblowing training and were not aware of the processes to follow to raise any concerns.
• A health and safety and legionella risk assessment had not taken place as required by legislation.
• Feedback from staff about poor performance of colleagues was not acted upon in an effective manner and records were not kept.
• Dental nurses had received training in relation to infection control but were not supervised adequately and were not following published guidance.
• Staff had been trained to handle emergencies and appropriate medicines and life-saving equipment was readily available but not sufficiently accessible. Staff were unaware how to use the emergency oxygen.
• There was no infection control policy or identified lead for infection control. Infection control procedures were not robust and the practice staff were not following published guidance.
• Infection control audits were not taking place in line with guidance and did not identify where systems were failing.
• Instruments designed for single use only were being sterilised and re-used.
• Procedures and guidelines for the safe taking of X-rays were not being followed. Unqualified staff were taking X-rays. The quality of X-rays was not being audited. The provider was not aware of the identity of the radiation protection advisor or supervisor. There was no radiation protection documentation available at the practice.
• There was a lack of evidence to demonstrate that a system was in place to review patients’ medical histories.
• National patient safety and medicines alerts were not being acted upon or cascaded to other dentists. There was no system in place to receive updates about best practice and legislation changes guidelines in dentistry.
• Patients received clear explanations about their proposed treatment, costs, benefits and risks and were involved in making decisions about it.
• Patients were treated with dignity and respect and confidentiality was maintained.
• The appointment system met the needs of patients and waiting times were kept to a minimum.
• There was no system in place that identified the type of staff training that was required and the frequency of it. Staff training and completion of it was not being monitored.
• The complaint system was ineffective. Patients’ complaints were not being handled with a duty of candour and not dealt with to the satisfaction of patients. Learning was not being identified and cascaded to staff at the practice.
• There was no recruitment policy for staff to follow. Recruitment procedures were not effective.
• There was no appraisal system in place, staff were not receiving appraisals and their competency was not being assessed.
• There was a lack of visible leadership from the provider.
• The provider had a lack of knowledge about the Health and Social Care Act Regulations and how they affected their dentistry role.
• There were no regular staff meetings taking place. Those that did take place were not minuted. There was no other system in place to reflect that governance issues were being discussed and the learning from significant events, complaints, safety issues or areas for improvement that had been identified.
• There was no system in place to assess and monitor the quality of the services they provided. There was no evidence that clinical and non-clinical audits were taking place.
• Governance systems were ineffective. There was an absence of key policies to support staff in the workplace and to set standards of performance.
• The practice did not seek feedback from staff and patients about the services they provided.
• The new practice manager had not received a job description, support or guidance for their new role.
• Staff were unclear about their responsibilities or who the leads were for governance at the practice.
• The absence of historical documentation to support compliance with the regulations reflected a lack of leadership and poor quality of care.

As a result of our second visit to the practice, we checked the progress that had been made and established that the provider had made some improvements and work was in progress on others. However the provider must:

• Ensure staff are following guidance in relation to the wearing of personal protective equipment when cleaning used instruments and that cleaning solutions are measured correctly and at the correct temperatures. Undertake a health and safety and legionella risk assessment as required by health and safety legislation.
• Ensure a robust recruitment process is in place and followed, including record keeping in relation to the documentation as highlighted in Schedule 3 of the Health and Social Care Act regulations. This includes ensuring that staff currently employed are appropriately qualified, experienced and skilled to carry out their roles.
• Implement a system so that staff working at the practice receive support, training, professional development, supervision and appraisal to enable them to carry out their duties. This includes safeguarding, infection control, whistle blowing training, supporting staff to undertake their continuous professional development and providing evidence of registration with their professional association. Implement a procedure for managing disciplinary and under performance issues.
• Ensure that there is a system in place to assess, monitor and improve the quality of services provided, including clinical and non-clinical audit cycles, the risks to patients and staff, infection control, maintaining accurate records for each patient to reflect the care and treatment received. Maintain staff records in relation to their employment, qualifications, training and management of the regulated activities.
• Implement a system to obtain feedback from staff and patients about the services provided at the practice.
• Ensure staff are aware of consent issues relating to children and young persons including the requirement for dentists to carry out mental capacity assessments where required.

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 radiation protection documentation is kept up to date and that staff are aware of the correct procedures to follow.

During our previous inspection on 10 May 2013 and 13 May 2013, we found that the provider was not complaint with regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2010.

During our unannounced follow – up inspection we found that the provider had made the required improvements and were now compliant with the regulation.

Staff we spoke with where aware of the practices safeguarding policy and procedures and knew how and where to report any suspicions of abuse.

On the 2 November 2012, we found the practice wasn’t meeting the regulation in relation to safeguarding people from abuse. We received an action plan from the provider on the 14 January 2013, telling us what action they would take to meet this essential standard. We were told that the practice would be meeting the requirements of the regulation by 12 March 2013. During our follow up inspections on the 10 and 13 March 2013, we found the provider was still not meeting the requirements of the regulation. On this occasion we did not speak with people who used the practice.

People that we spoke with said that they were happy with the treatment that they had received. People that we spoke with told us that they were always able to get and appointment at short notice in the case of an emergency. A person that we spoke with said “The appointment system works well for me ".