We carried out an announced comprehensive inspection of this practice on 24 May 2016. A breach of legal requirements was found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to good governance.

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 Shams Moopen Dental Practice on our website at www.cqc.org.uk

Our findings were:

Are services well-led?

We found that this practice was providing well-led care in accordance with the relevant regulations.

Background

Shams Moopen Dental Practice provides general dentistry and orthodontics to adults and children.

The practice is situated over four floors of a converted townhouse in the Kingsley area of Northampton. The practice mostly provides treatment (90%) on the NHS, and the remainder pay privately for their treatment.

The practice was first registered with the Care Quality Commission (CQC) in July 2011.

The practice’s opening hours are 8.30 am to 6.30 pm Monday to Thursday. 8.30 am to 4.30 pm on Friday.

Access for urgent advice or treatment is by contacting a nearby practice in Northampton before 8 pm (the contact number of which is detailed on the answer machine) or by using the NHS 111 after 8 pm.

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.

Our key findings were:

• Infection Control and X-ray audits had been completed and were effective in monitoring the quality of clinical care; however the infection control audit had been completed once in the preceding year, national guidance recommends the audit be completed six monthly.

• Equipment was mostly maintained and tested in line with manufacturer’s guidance. With the exception of the compressor which was tested following the inspection.

• A fire risk assessment had been carried out in April 2017 and identified risks had been addressed at the time or shortly after the follow- up inspection.

• Rectangular collimators had been fitted to all X-ray machines in line with recommendations made to the practice.

• Procedures for decontamination of instruments were observed to be in line with National guidance.

• A Legionella risk assessment had been carried out after our comprehensive inspection and the practice were complying with the recommendations.

• A previously obstructed fire exit door had been entirely cleared to allow for evacuation in an emergency.

• Clinical waste bins were secured to prevent removal.

• Clinical references had been sought for a new employee in the last year.

We carried out an announced comprehensive inspection on 24 May 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 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

Shams Moopen Dental Practice provides general dentistry and orthodontics to adults and children.

The practice is situated over four floors of a converted townhouse in the Kingsley area of Northampton. The practice mostly provides treatment (90%) on the NHS, and the rest pay privately for their treatment.

The practice was first registered with the Care Quality Commission (CQC) in July 2011.

The practice’s opening hours are 8.30 am to 6.30 pm Monday to Thursday. 8.30 am to 4.30 pm on Friday.

Access for urgent advice or treatment is by contacting a nearby practice in Northampton before 8 pm (the contact number of which is detailed on the answer machine) or by using the NHS 111 after 8 pm.

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.

We received positive feedback from 32 patients about the service. This was through Care Quality Commission comment cards left at the practice prior to our visit.

Our key findings were

• The premises were visibly clean and tidy and clutter free.

• Patients commented that they were treated in a kind and friendly manner, and that clinicians explained everything to them in detail.

• The practice took immediate steps to rectify some failings that were identified in their cross infection procedures.

• The practice did not set aside emergency appointments, patients would mostly be seen on the day they contacted the practice.

• The practice had policies in place to ensure the smooth running of the service, however these were not dated and so staff could not be assured that the information was up to date.

• The provider had emergency medicines in line with the British National Formulary (BNF) guidance for medical emergencies in dental practice.

• Certain required risk assessments had not been carried out (although arrangements were made after the inspection) and where risk assessments had been completed the actions highlighted had not always been addressed.

• A full oral screening was carried out on patients who attended the practice, this included assessment of gum health and soft tissues of the mouth and face.

• Level access to the premises for wheelchair users or those with limited mobility could be achieved through the front door, and more recently a ramp had been added to the car park to allow access from the car park.

• The practice used a system of safer sharps which greatly reduced the risk of needlestick injury to staff.

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

• Ensure effective systems and processes are established to assess and monitor the service against the requirements 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 the practice’s protocols for the use of rubber dam for root canal treatment giving due regard to guidelines issued by the British Endodontic Society

• Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and Gillick competency and ensure all staff are aware of their responsibilities.

• Review the protocols and procedures to ensure staff are up to date with their mandatory training and their Continuing Professional Development, including training in X-rays in line with regulation.

• Review audit protocols to document learning points that are shared with all relevant staff and ensure that the resulting improvements can be demonstrated as part of the audit process.

We returned to complete a follow up inspection to check that the action which had arisen following our last inspection in March 2013 had been completed. At this inspection we found that there had been improvements in the recruitment process as appropriate checks were now in place before staff commenced employment. We found that for those staff who did not require a disclosure and barring service (DBS) check due to their job role that risk assessments were in place for all staff.

We saw that the changes that had been made to the windows at the property had improved the privacy and dignity of people who were receiving treatment. We observed that the treatment room windows which overlooked the car park were now glazed with a frosted covering.

We spoke with people who were happy with the service they had received from the staff at Shams Moopen Dental Practice. One person told us that they had recently joined the practice as it had been recommenced by a friend. Another person was pleased to see that a translation service was available as she was accompanying a friend who did not speak any English.

We saw that the ongoing refurbishment of the interior of the building would improve access for people who had mobility problems. We had concerns that staff were employed before checks which ensured they were of good character was completed.