We carried out an unannounced focused inspection on 25 November 2016 to check on the actions taken by the dental provider to make the required improvements which were identified when we carried out a comprehensive inspection on 5 August 2016.

When we carried out a comprehensive inspection on 5 August 2016 we identified areas where improvements were required:

• Risks to the health, safety and welfare of patients and staff were not assessed or managed. Policies and procedures were not routinely followed. The results from risk assessments in relation to fire, health and safety and legionella were not reviewed or acted upon.
• Staff had not undertaken training in relevant to their roles and did not fully understand their responsibilities in relation to areas including radiation protection, safeguarding and infection control.
• Audits and reviews were not carried out to monitor and make improvements to the delivery of the service.

Following this inspection we served the practice with warning notices, in line with our enforcement methodology, in relation to a breach of Regulation 12 Safe care and treatment and Regulation 17 Good governance in line with our enforcement methodology.

Our findings from our unannounced focused inspection on 25 November were:

Are services safe?

We found that this practice was providing safe 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

Patient First Dental Practice is a dental practice situated in Grays, Essex.

The practice has four treatment rooms, a combined waiting room and reception area. Decontamination takes place in a dedicated decontamination room (Decontamination is the process by which dirty and contaminated instruments are bought from the treatment room, washed, inspected, sterilised and sealed in pouches ready for use again).

The practice is a partnership between two dentists. Four associate dentists, a hygienist, four qualified dental nurses, one trainee dental nurse and one receptionist are employed at the practice.

One of the principal dentists 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.

The practice offers NHS and private general and cosmetic dental treatments to adults and children. The opening hours of the practice are 9 am to 5 pm Monday to Friday and 9 am to 2 pm on Saturdays. The practice offers late evening appointments up to 9 pm on Thursday evenings. Appointments are available throughout these times, including lunch times.

Treatments using conscious sedation techniques are carried out Saturday each month by pre-arranged appointment. (These are techniques in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation). The conscious sedation techniques were carried out by an external professional, supported by one of the dentists who had undertaken training in this area.

Our key findings were:

• The practice had systems in place for investigating and learning from safety incidents or accidents. Learning from incidents and complaints was used to make improvements where this was required.
• The practice was visibly clean and infection control practices met national guidance. There were systems in place to minimise the risk of legionella and infection control audits were carried out.
• There were a number of systems in place to help keep people safe, including safeguarding vulnerable children and adult procedures.
• There were arrangements in place to assess and manage risks in relation to the premises, equipment and the risk of fire. A range of risk assessments had been carried out and where areas for improvement were identified these were acted upon.
• There were systems in place to ensure that X-ray equipment was tested and maintained safely. Staff undertook relevant training and had access to information to ensure that X-rays were carried out safely and that risks to patients and staff were minimised.
• Staff undertook relevant training in respect of their roles and responsibilities within the practice.
• The practice kept medicines and equipment for use in medical emergencies. These were in line with national guidance and regularly checked so that they were fit for use.
• Effective governance arrangements were in place for the smooth running of the service.
• Patient’s views were sought and used to make improvements to the service where these were identified.

We carried out an announced comprehensive inspection on 5 August 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 not 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

Patient First Dental Practice is a dental practice situated in Grays, Essex.

The practice has four treatment rooms, a waiting room and a reception area. Decontamination takes place in a dedicated decontamination room (Decontamination is the process by which dirty and contaminated instruments are bought from the treatment room, washed, inspected, sterilised and sealed in pouches ready for use again).

The practice is a partnership between two dentists. Four associate dentists, a hygienist, six qualified dental nurses, one trainee dental nurse and one receptionist are employed at the practice.

The principal dentist 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.

The practice offers NHS and private general and cosmetic dental treatments to adults and children. The opening hours of the practice are 9 am to 5 pm Monday to Friday and 9 am to 2 pm on Saturdays. The practice offers late evening appointments up to 9 pm on Thursday evenings. Appointments are available throughout these times, including lunch times.

We left comment cards at the practice for the two weeks preceding the inspection. 12 people provided feedback about the service in this way. All of the comments spoke highly of the dental care and treatment that they received and the professional and helpful attitude of the dentists and dental nurses.

Our key findings were:

• The practice had systems in place for investigating and learning from safety incidents or accidents. However learning from complaints was not used to make improvements where this was required.
• The practice was visibly clean and clutter free. However Infection control practices did not meet national guidance. There were limited systems in place to minimise the risk of legionella and no infection control audits were carried out.
• There were systems in place to help keep people safe, including safeguarding vulnerable children and adults. However there were no health and safety risk assessments in place.
• There were systems in place to ensure that X-ray equipment was tested and maintained safely. Staff did not have access to training or information to ensure that X-rays were carried out safely and that risks to patients and staff were minimised.
• Dental care and treatments were carried out in line with current legislation and guidelines.
• Staff did not receive all the relevant training in respect of their roles and responsibilities within the practice.
• Patients reported that they were treated with care and compassion and staff were polite and helpful.
• Patients were involved in making decisions about their care and treatments.
• The practice provided a flexible appointments system and could normally arrange a routine appointment within a few days or emergency appointments mostly on the same day.
• The practice kept medicines and equipment for use in medical emergencies. These were in line with national guidance and regularly checked so that they were fit for use.
• Effective governance arrangements were not in place for the smooth running of the service. There were limited measures in place to ensure that the policies and systems within the practice were monitored, reviewed as needed and adhered to by staff,
• Patient’s views were sought. However these were not used to make improvements to the service where these were identified.

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

• Ensure that all of the appropriate checks are carried out when recruiting new staff to work at the practice.
• Ensure an effective system is established to assess, monitor and mitigate the various risks arising from undertaking of the regulated activities. This includes assessing and managing the risks associated with the use of X-ray equipment and exposure to ionising radiation, infection control including legionella. It also includes reviewing safety alerts and taking any relevant action to mitigate risks to patients and reviewing safety related incidents and using learning from these to make necessary improvements.

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

• Review its procedures for dealing with medical emergencies to determine the need for portable suction equipment.
• Review the arrangements for the Control of Substances Hazardous to Health (COSHH) so that this information is updated to include any new materials used / any changes to information about currently used substances.
• Review the systems for monitoring prescription pad use and recording details of prescriptions issued.
• Review the records in relation to cleaning and decontamination procedures so that these include a record of checks carried out at start and close of day.
• Review staff records so that they accurately reflect training undertaken.
• Review the procedures for obtaining patient consent so that these include reference to the Mental Capacity Act 2005 and making best interests decisions where patients lack capacity to give consent or make informed decisions about their care and treatment.
• Review and monitor patient waiting times and improve on these where this is practicable.
• Review the arrangements for advising patients about the practice complaints procedures and how they can make complaints.

We carried out this responsive follow up inspection to check on the improvements made to the service following our inspection in August 2013.

At that time we identified that improvements were required to ensure that people were protected against the risk of health acquired infections and unsafe or unsuitable care and treatment.

When we revisited the service in May 2014 we found that the required improvements to the service had been made.

There was a dedicated decontamination area for cleaning and sterilising reusable dental instruments. Equipment for cleaning and sterilising these instruments was checked and serviced appropriately. The premises were clean and there were cleaning schedules for staff to follow. The arrangements for protecting people against the risks of health acquired infections were regularly monitored.

There were procedures for ensuring that people were protected against the risks of unsafe or unsuitable care and treatment. People's views were sought in respect of their experience of using the service. There were systems for auditing the quality and safety of the services provided so as to minimise risks to people and to ensure that people received safe and effective care and treatment.

People we spoke with during our visit in August 2013 told us that they were very happy with the care and treatments they received at the practice. People said that treatments were explained to them in a way that they could understand. They told us that they felt safe and well cared for and that staff were kind and caring.

We saw that appropriate assessments of each person's oral health needs were carried out before each treatment. People were offered a choice of treatments where possible and consent to treatment was obtained. There were arrangements in place to deal with any foreseeable medical emergencies and staff were trained to support people.

The premises were clean and well maintained. There were procedures for cleaning and sterilising equipment and dental instruments. However improvements were needed such as testing and monitoring the systems in place for minimising the risks of cross infection.

Staff received training and support to enable them to carry out their duties and care for people safely and effectively. There were arrangements in place for safeguarding people from the risks of abuse or harm.

Some areas of the services provided were not regularly monitored as part of an overall quality improvement system. There was no effective system for testing and improving the quality and safety of the service.

The service was not meeting all the standards for quality and safety across each of the outcome areas we inspected.