We carried out a focused inspection of Smile Dental Care Pinetrees on 4 July 2018.

The inspection was led by a CQC inspector who was supported by a specialist dental adviser.

We carried out the inspection to follow up concerns we originally identified during a comprehensive inspection at this practice on 20 February 2017 and a focussed inspection on 11 January 2018 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 on 20 February 2017 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. At the focussed inspection on 11 January 2018 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 reports of those inspections by selecting the 'all reports' link for Smile Dental Care Pinetrees on our website www.cqc.org.uk.

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 put right the shortfalls and deal with the regulatory breach we found at our inspection on 11 January 2018.

There were areas where the provider could make improvements. They should:

• Review the practice’s infection control procedures and protocols taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’ in particular the adoption of more efficient and effective validation processes for the autoclave and ultrasonic cleaner, marking of sinks to aid staff when using volume related cleaning products, adoption of a written protocol should the autoclave fail, reviewing of check lists used to ensure staff fully understand them, and consideration around the processing of reverse osmosis (RO) water.

We carried out a focused inspection of Smile Dental Care Pinetrees on 11 January 2018.

We carried out the inspection to follow up concerns we originally identified during a comprehensive inspection at this practice on 20 February 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 area(s) 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 Smile Dental Care Pinetrees on our website www.cqc.org.uk.

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

Our findings were:

Are services well-led?

We found this practice was not providing well-led care in accordance with the relevant regulations.

The provider had made some improvements to put right the shortfalls and deal with the regulatory breaches we found at our inspection on 20 February 2017.However there were still significant areas that had not been addressed.

We identified regulations the provider was not meeting. They must:

• Ensure systems and processes in place for good governance are operated effectively in accordance with the fundamental standards of care. This includes

• Ensure all premises and equipment used by the service provider is fit for use and properly maintained. For example ensure decontamination equipment is serviced in a timely way.

• Ensure activities at the practice are assessed, monitored and the information obtained used to mitigate risks and improve the service. For example monitoring of staff training and taking action following audit analysis to improve the service.

• Ensure persons employed in the provision of the regulated activities receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties. For example managing poor performance in staff.

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:

• Adequately address through policy and training the correct fire procedures and checks.

We carried out an announced comprehensive inspection on 20 February 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 this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

We found this practice was providing effective care in accordance with the relevant regulations.

Are services caring?

We found this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found this practice was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found this practice was not providing well-led care in accordance with the relevant regulations.

Background

Smile Care Dental Pinehurst is a dental practice providing mainly NHS treatment for adults and children.

The practice is based in a Community Centre owned by the Local Authority, with off road car parking. The practice lease part of the building on the ground floor which consists of a waiting area with open reception, one disabled and wheelchair accessible toilet, two treatment rooms and a separate room for the cleaning, sterilising and packing of dental instruments. The practice is easily accessible via automatic entrance doors.

The practice employs two dentists and at the time of the inspection one was a locum. There was one dental nurse and one trainee dental nurse, three receptionists and a practice manager.

The practice opens: Monday: 8.30am- 5.30pm, Tuesday: 8.30am- 5.30pm, Wednesday: 8.30am- 5.30pm, Thursday: 8.30am- 5.30pm, Friday: 8.30am- 5.30pm, Saturday: Closed, Sunday: Closed.

There are arrangements in place to ensure patients receive urgent dental assistance when the practice is closed. This is provided by an out-of-hours service by calling NHS 111.

The practice manager is currently in the process of applying to be 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.

Before the inspection, we sent Care Quality Commission comment cards to the practice for patients to complete to tell us about their experience of the practice. We received feedback from 11 patients. In addition we spoke with two patients on the day of our inspection. Feedback from patients was positive about the quality of care, the caring nature of all staff and the overall high quality of customer care. They commented that staff put them at ease and listened to their concerns. They also reported they felt proposed treatments were fully explained them so they could make an informed decision which gave them confidence in the care provided.

Our key findings were:

• We found that the dentists’ approach to treatment was to provide patient centred dental care in a relaxed and friendly environment.
• The dentists provided dental care in accordance with current professional and National Institute for Care Excellence (NICE) guidelines.
• Premises appeared well maintained and visibly clean.
• The dentist used ‘Loupes’ – these enable the clinician to have a magnified view of the operation site thus enabling accuracy of treatment.

• Infection control procedures were effective and the practice followed published guidance although the infection control decontamination policy did not reflect the equipment in use.
• Staff had been trained to handle emergencies and appropriate medicines and life-saving equipment was readily available in accordance with current guidelines. However there was no documented operational policy relating to the management of such emergencies.
• Although the dentists provided effective clinical care leading to good patient outcomes, there were shortfalls in the clinical governance systems and processes underpinning the clinical care. This included policies that were not specific and personalised for the practice.
• There were systems in place to check all equipment had been serviced regularly, including the autoclave.
• The practice had a system to monitor and continually improve the quality of the service. This included a programme of clinical audits, although improvements could be made to the system used to audit radiographs by including an analysis of the various grades of quality of X-rays over each audit cycle.
• Patients could access treatment and urgent and emergency care when required.
• Information from 11 completed Care Quality Commission (CQC) comment cards and speaking to patients gave us a positive picture of a friendly, caring and professional service.
• The practice carried out pre-employment recruitment checks but these were not always fully completed.
• The staff had received training relevant to their role but the arrangements for identifying the ongoing learning and development needs of staff members and the on-going assessment and supervision of all staff employed was not well established.

• The practice reviewed and dealt with complaints according to their practice policy.

• The practice was developing information for patients and their arrangements for patient feedback.

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

• Ensure an effective system is established to assess, monitor and mitigate the various risks arising from undertaking the regulated activities.

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

• Review their infection control policy to include provision of an annual statement in relation to infection prevention control as required under The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.
• Review their infection control arrangements and identify a nominated lead professional.
• Review the audit process for the quality of radiographs to include an analysis of the various grades of quality of X-rays over each audit cycle.
• Review the system for monitoring and recording equipment and when equipment requires servicing.
• Review the need for a documented operational policy and procedure for managing medical emergencies.

Review the practice safeguarding policy to include the nominated lead professional.