We carried out a focused inspection of Precious Smile (Watford) on 23 November 2017.

The inspection was led by a CQC inspector who was supported by a second CQC inspector.

We carried out the inspection to follow up concerns we originally identified during a comprehensive inspection at this service on 25 January 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions.

At a comprehensive inspection we always ask the following five questions to get to the heart of patients’ experiences of care and treatment:

• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well-led?

When one or more of the five questions is 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.

At the previous comprehensive inspection we found the registered provider was providing safe, effective, caring and responsive care in accordance with relevant regulations. We judged the practice was not providing well-led care in accordance with regulation 17 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 Precious Smile (Watford) on our website www.cqc.org.uk.

We also reviewed aspects of the key questions of safe and effective as we had made recommendations for the provider relating to this key question. We noted that improvements had been made.

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 to rectify the shortfalls and deal with the regulatory breach we found at our inspection on 25 January 2017.

We carried out an announced comprehensive inspection on 25 January 2017 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

Precious Smiles (Watford) is a mobile dental service providing dental care to patients who are unable to attend a dental practice. There is one dentist and one trainee dental nurse who visit patients in their own home or care facility.

The service is operated from a residential property in Watford, but these premises are administrative only and patients are not seen here as there is no treatment room on site. There is an office and a decontamination room.

Both the dentist and the trainee dental nurse work part time and provide care most commonly on a Saturday, but occasionally in the evenings if the urgency of the situation demands it. On average the service was treating approximately three patients per week at the time of the inspection.

The service offers a range of dental treatment; most commonly the provision of dentures, also simple extractions and fillings. Recently they started providing X-rays if required by means of a hand held X-ray unit.

The principal dentist is registered with the Care Quality Commission (CQC) as an individual. 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 received feedback from patients by way of comment cards that we sent to the service two weeks prior to our inspection, and from interviewing staff at care homes where services are provided by Precious Smiles (Watford). We received feedback from six people in this way.

Our key findings were:

• Staff were committed to providing good dental care to vulnerable people who were unable to access dental services in other ways.

• Staff had been trained in medical emergencies and took the medical emergencies kit with them to all visits.

• Patients and care homes commented that the service provided was of high quality, and could be accessed in a timely manner.

• The dentist used nationally recognised guidance in the care and treatment of patients.

• The practice did not meet national guidance in some of the aspects of infection control; however changes were made immediately following the inspection.

• The practice had appropriate systems in place to ensure they employed fit and proper persons.

• Patients received clear explanations about their proposed treatment and were involved in making decisions about it.

• Staff had a good understanding of most of the aspects of the Mental Capacity Act and it’s relevance in obtaining consent to treat.

• The medical emergencies kit was missing a medicine to treat low blood sugar, as well as three sizes of oro-pharyngeal airway that are recommended in national guidance.

• The practice had recently introduced a new system of governance. Comprehensive policies and protocols were available, but had not always been fully implemented at the time of the inspection.

• The practice was not carrying out clinical audit in infection control.

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

• Ensure effective systems are in place in order that the regulated activities at Precious Smile (Watford) are compliant with the requirements of Regulations 4 to 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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:

• Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.

• Review its responsibilities as regards to the Control of Substance Hazardous to Health (COSHH) Regulations 2002 and, ensure all documentation is up to date and staff understand how to minimise risks associated with the use of and handling of these substances.

• Establish whether the practice is in compliance with its legal obligations under Ionising Radiation Regulations (IRR) 99 and Ionising Radiation (Medical Exposure) Regulation (IRMER) 2000.

• 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).