We carried out an announced follow-up inspection at Provident Dental Surgery on the 3 August 2017. This followed an announced comprehensive inspection on the 8 June 2017 carried out as part of our regulatory functions where breaches of legal requirements were found.

After the comprehensive inspection, the practice wrote to us to say what actions they would take to meet the legal requirements in relation to the breaches.

We revisited Provident Dental Surgery and checked whether they had followed their action plan.

We reviewed the practice against three of the five questions we ask about services: is the service safe, effective and well-led? 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 Provident Dental Surgery on our website at www.cqc.org.uk.

Background

This inspection was planned to check whether the practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The follow-up inspection was led by a CQC inspector who was supported by a specialist dental advisor.

During our inspection visit, we checked that points described in the provider’s action plan had been implemented by looking at a range of documents such as risk assessments, staff files, policies and staff training.

Our key findings were:

• The practice had infection control procedures which were reflective of published guidance. There were systems in place to ensure that sterilised instruments were stored in line with the guidance.
• There were systems in place to ensure that all equipment used to sterilise instruments was validated as per national guidelines; and maintained as per manufacturer’s recommendations.
• Staff knew how to deal with medical emergencies. All appropriate medicines and life-saving equipment were available, including an automated external defibrillator; and all necessary checks on expiry dates and functionality were being completed.
• Risks related to undertaking of the regulated activities had been suitably identified and mitigated.
• The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
• The practice had thorough staff recruitment procedures.
• Consent was suitably obtained and documented.
• Effective systems were in place to suitably assess, monitor and improve the quality of the service.
• There was effective leadership at the practice and systems were in place to share information and learning amongst them.
• The practice had systems in place to seek feedback from staff and patients.

We carried out this announced inspection on 8 June 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.

We told Healthwatch that we were inspecting the practice. They did not provide any information.

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 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 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

Provident Dental Surgery is located in Worthing and provides private treatment to patients of all ages.

The practice is located on first floor premises. Car parking spaces are available near the practice.

The dental team includes one principal dentist and two trainee dental nurses who perform dual roles as receptionists. The practice has two treatment rooms, one of which is used to decontaminate dental instruments.

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 received feedback from three patients. This information gave us a positive view of the practice.

During the inspection we spoke with the principal dentist and one trainee dental nurse. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open: Monday to Friday from 9am to 5.30pm and Saturday from 9am to 1pm.

Our key findings were:

• The practice was clean and most equipment was maintained in line with manufacturer’s recommendations and guidance.
• The practice had infection control procedures which were reflective of published guidance. However these were not adhered to or followed by staff.
• Staff lacked knowledge in how to deal with emergencies. Appropriate medicines and life-saving equipment were available with the exception that an automated external defibrillator (AED) was not available.
• Risks related to undertaking of the regulated activities had not been suitably identified and mitigated.
• Dental care and treatment was being provided using conscious sedation without taking into account current national guidelines.
• Staff lacked knowledge of their responsibilities for safeguarding adults and children. Improvements were required to the practice’s safeguarding processes.
• The practice lacked thorough staff recruitment procedures.
• Consent was not suitably obtained and documented.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• The appointment system met patients’ needs.
• Effective systems were not in place to suitably assess, monitor and improve the quality of the service.

We identified regulations the provider was not meeting. 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 sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment
• 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 specified information is available regarding each person employed.

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 practice's policy and the storage of products identified under Control of Substances Hazardous to Health (COSHH) 2002 Regulations to ensure a risk assessment is undertaken and the products are stored securely.
• 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).
• Review the practice’s sharps procedures and ensure the practice is working in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
• Review the practice’s protocols for the use of rubber dam for root canal treatment taking into account guidelines issued by the British Endodontic Society.
• Review the practices’ Legionella risk assessment and implement the required actions taking into account guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and have regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.’
• Review the protocols and procedures for use of X-ray equipment taking into account Guidance Notes for Dental Practitioners on the Safe Use of X-ray Equipment.
• 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 ensuring compliance with the Ionising Radiation (Medical Exposure) Regulations (IRMER) 2000.
• Review the systems in place to ensure that care and treatment of patients is only provided with the consent of the relevant person.
• Review the systems and processes in place to ensure that these are established and operated effectively to safeguard service users.

The principal dentist was made aware of our findings on the day of the inspection and they were formally notified of our concerns immediately after the inspection. They were given an opportunity to put forward an urgent action plan with remedial timeframes, as to how the risks could be mitigated.

The provider responded appropriately within the required time frame to inform us of the urgent actions they had undertaken to mitigate the risks. These included voluntary cessation of the provision of dental care using conscious sedation at the practice and in a domiciliary setting with immediate effect.

At the previous inspection in March 2013 we identified various shortfalls. At this inspection we found that the provider had satisfactorily addressed all our previous concerns.

We saw that the provider had revised the patient leaflet and removed the misleading statement about treatment available under the National Health Service (NHS). We also saw that the provider is currently undertaking a patient survey to capture patient’s comments about the service.

We reviewed 15 medical records and saw that in the majority of cases they included completed treatment plans and patient consent. Where there was no treatment plan the provider explained that they always took verbal consent prior to treatment and we saw that this was recorded. The provider has made suitable arrangements to obtain patients consent to treatment.

The medical records showed that patient’s medical histories had been updated at their last appointment. They also showed details about treatment options.

We looked at the decontamination and infection control records. We found that the provider had maintained up to date records of daily, weekly and monthly checks. We also saw that the provider had taken action following an infection control audit they had undertaken in March 2013.

We saw that the provider had a training programme in place that they used to train clinical staff. The dental nurses confirmed they were undertaking formal training with an outside body and they were well supported by the provider.

We saw that the practice had appropriate systems in place to manage emergencies. We saw evidence that equipment was routinely serviced and maintained

We were unable to speak with patients at the time of our inspection as there were no appointments booked. The provider told us they had not conducted a patient survey “for a few years” and so we were unable to see the views from this source. A suggestion box was available in the surgery. A small number of comments had been left and most were favourable. However, one person commented that the dentist should wait longer for the anaesthetic to take effect because they were in pain when they were having their treatment. The dentist was unable to advise us as to how this had been addressed.

We were concerned about the level of non-compliance that we found during our inspection and urgent action is required to improve the following: patient information and involvement; consent practices; the planning and delivery of care and treatment; infection control practices; support for staff and governance.