We undertook a follow up desk-based inspection of Shaw Village Dental Practice on 27 March 2019. This inspection was carried out to review in detail the actions taken by the registered provider to improve the quality of care and to confirm that the practice was now meeting legal requirements.

The inspection was led by a CQC inspector.

We undertook a comprehensive inspection of Shaw Village Dental Practice on 11 September 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We found the registered provider was not providing well-led care and was in breach of 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 Shaw Village Dental Practice on our website www.cqc.org.uk.

As part of this inspection we asked:

• Is it well-led?

When one or more of the five questions are 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.

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 in relation to the regulatory breaches we found at our inspection on 11 September 2018.

Background

Shaw Village Dental Practice is in the North West of Swindon and provides private treatment to adults and children.

The practice is situated above a commercial business and is accessed by climbing a flight of stairs. The practice informs all new patients choosing to register that they are not wheelchair accessible; they signpost patients that cannot climb the stairs to a nearby practice. There is a free car park directly outside the practice which has spaces available for blue badge holders.

The dental team includes three dentists, two dental nurses, two dental hygienists, one receptionist and one practice administrator. The practice has three treatment rooms.

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.

During the follow-up desk based inspection we spoke with the practice manager. We were sent copies of completed infection prevention control and radiography audit results, servicing certification for fire equipment and the gas boiler, evidence of a legionella risk assessment certification and practice meeting minutes detailing patient safety alert discussions.

The practice is open:

Monday to Thursday from 9am to 5.30pm and Friday from 9am to 2.30pm.

Our key findings were:

• Audit activity had significantly improved. Infection prevention and control audits and radiography audits had been completed within appropriate timeframes in line with published guidance.

• There were improved systems and processes established to enable the registered person to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk. Patient safety alerts were monitored and reviewed, legionella risk assessment actions had been implemented, servicing and maintenance of equipment had been completed.

We carried out this announced inspection on 11 September 2018 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.

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 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

Shaw Village Dental Practice is in the North West of Swindon and provides private treatment to adults and children.

The practice is situated above a commercial business and is accessed up a flight of stairs. The practice informs all new patients wishing to register that they are not wheelchair accessible and signposts patients that cannot manage the stairs to a nearby practice. There is a free car park directly outside the practice which has spaces available for blue badge holders.

The dental team includes three dentists, two dental nurses, two dental hygienists, one receptionist and one practice administrator. The practice has three treatment rooms.

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 collected 26 CQC comment cards filled in by patients.

During the inspection we spoke with one dentist, two dental nurses, one dental hygienist and the practice administrator. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Thursday from 9am to 5.30pm and Friday from 9am to 2.30pm.

Our key findings were:

• The practice appeared clean and well maintained although we were not shown cleaning schedules and there was only one mop in use. We were sent copies of the cleaning schedule and advised additional mops had been ordered in line with the cleaning schedule following our visit.
• The provider had infection control procedures which mostly reflected published guidance. The practice had not completed any testing on the ultrasonic machine.
• Not all equipment had been serviced in line with manufacturers guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available with the exception of buccal midazolam. We found out of date self-inflating bags and masks and the oxygen cylinder was not the correct size as outlined in the resuscitation council guidelines. These items were immediately ordered and replaced.
• The practice had some systems to help them manage risk to patients and staff. The practice had failed to implement recommendations following a legionella risk assessment.
• The practice staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The provider had staff recruitment procedures. We found that one staff member had not received a disclosure and barring service check and photographic identification was not on file for all staff members.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• The provider was providing preventive care and supporting patients to ensure better oral health.
• The appointment system met patients’ needs.
• Staff felt involved and supported and worked well as a team.
• The practice did not complete audits of various aspects of the service, such as radiography, record keeping and infection prevention and control at regular intervals to help improve the quality of service.
• The practice asked staff and patients for feedback about the services they provided.
• The provider dealt with complaints positively and efficiently.
• The provider had suitable information governance arrangements.

We identified regulations the provider was not complying with. They must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulation 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 recruitment policy and procedures to ensure accurate, complete and detailed records are maintained for all staff.

• 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).

We had the opportunity to speak with three patients who told us that they had received information about the service. They said that the dentist always explained their treatment options. There was information about the service, treatment options and costs in the waiting room.

People's care and treatment was planned and delivered in a way that met their needs. People told us that if they needed treatment they had a treatment plan with the costs. They also said that the dentist took a medical history and asked them to update this every

time they had a check up.

People were treated in an environment which was clean and hygienic. The people we spoke with told us that the surgery was clean and hygienic. They also said how safe they felt with the staff.

There was a patient survey so that people could give their views about the service. The provider was introducing improvements in response to comments. They were also introducing auditing systems to make sure the service provided was safe.