We carried out this announced inspection on 25 October 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 providing well-led care in accordance with the relevant regulations.

Background

Toothcare Ltd is in Canvey Island in Essex, and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Four car parking spaces are available at the rear of practice.

The dental team includes one dentist, one dental nurse and one trainee dental nurse, one administrator, one receptionist and a practice manager. The practice has one treatment room and one decontamination room.

The practice is owned by a company and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run. The registered manager at Toothcare Ltd is the principal dentist.

On the day of inspection, we collected 25 CQC comment cards filled in by patients and spoke with two other patients.

During the inspection we spoke with one dentist, one dental nurse, one receptionist and the practice manager. 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 closes from 12.30pm to 2pm daily. The practice is open until 7.30pm on Tuesday evenings.

Our key findings were:

• The practice appeared clean and well maintained.
• The practice staff had infection control procedures which reflected published guidance. We found some pouched clean instruments had dental cement still on them. We discussed this with the provider who confirmed these instruments would be re-sterilised following our inspection.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
• The practice had some systems to help them manage risk. We found there was no evidence that some actions recommended from the Legionella risk assessment had been completed.
• The practice staff had mostly suitable safeguarding processes. Staff demonstrated awareness of their responsibilities for safeguarding adults and children. We found that contact information for safeguarding teams was out of date. Following the inspection, the practice confirmed these had been updated.
• The practice had staff recruitment procedures; we found that some of these required strengthening.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• The appointment system met patients’ needs.
• Staff felt involved and supported and worked well as a team.
• The practice asked staff and patients for feedback about the services they provided.
• The practice staff dealt with complaints positively and efficiently.
• The practice staff had suitable information governance arrangements.

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

• Review the practice's protocols for completion of dental care records taking into account the guidance provided by the Faculty of General Dental Practice and review the practice’s protocols for recording in the patients’ dental care records or elsewhere the reason for taking X-rays, a report on the findings and the quality of the image in compliance with Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment.
• Review the practice’s recruitment procedures to ensure that appropriate checks are completed prior to new staff commencing employment at the practice.
• 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 the practice’s protocols and procedures for promoting the maintenance of good oral health giving due regard to guidelines issued by the Department of Health publication ‘Delivering better oral health: an evidence-based toolkit for prevention’.
• Review the practice’s protocols for the use of rubber dams for root canal treatment giving due regard to guidelines issued by the British Endodontic Society.
• Review the management of sharps procedures and ensure the practice is in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013

We carried out an announced comprehensive inspection on 27 May 2015 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 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

Toothcare offers primarily NHS care with some private treatments if requested. The staff structure of the practice consists of a principal dentist, a dental nurse, a receptionist and a trainee receptionist and dental nurse.

We spoke with three patients who used the service on the day of our inspection and reviewed seven CQC comment cards that had been completed by patients prior to the inspection. The patients we spoke with were complimentary about the service. They told us they found the staff to be friendly and informative. They felt they were treated with respect. The comments on the CQC comment cards were also very complimentary about the staff and the service provided.

During the inspection we spoke with four members of staff, including the principal dentist, who was also 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.

To further assess the quality of care provided by the practice, we looked at practice policies and protocols and other records

Our key findings were:

• Staff had received safeguarding and whistleblowing training and knew the processes to follow to raise any concerns.
• There were sufficient numbers of suitably qualified staff to meet the needs of patients.
• Staff had been trained to handle emergencies and appropriate medicines and life-saving equipment were readily available.
• Patients received clear explanations about their proposed treatment, costs, benefits and risks and were involved in making decisions about it.
• Patients were treated with dignity and respect and confidentiality was maintained.
• The appointment system met the needs of patients and waiting times were kept to a minimum.
• The practice sought feedback from staff and patients about the services they provided.

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

• Ensure dental X-rays are prescribed and managed according to current criteria guidelines
• Ensure the risk of legionella is mitigated by applying the current legislation and guidance such as, The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance.
• Ensure there are appropriate arrangements for managing medicines which include obtaining, prescribing, recording, handling, and security, dispensing safe administration and disposal.
• Assess the risks to the health and safety of patients receiving treatment.
• Maintain accurate, complete and contemporaneous record in respect of each patient, including a record of the care and treatment provided to the patient and of decisions taken in relation to the care and treatment provided.
• Evaluate and improve their practice by processing information gained from clinical practice, risk assessments and seeking and acting on feedback.

You can see full details of the regulations not being met at the end of this report.

When we visited the practice we found that the people who used the service and staff were protected against the risks of a health care related infection.

Instruments that had been used were being cleaned and sterilised in line with published guidance and then stored correctly. Records held at the practice demonstrated that the cleaning and sterilising equipment were in correct working order and subject to daily and weekly checks. Staff wore clean uniforms daily and did not wear them when travelling to and from work.

Staff were now receiving annual appraisals and regular supervision. Documents we viewed reflected that all staff had received an appraisal.

The provider now had a full range of audits to monitor the quality of the services they provided. Staff meetings took place regularly and minutes were taken.

When we visited the provider we spoke with four people who were regular users of the practice over a number of years. They all told us that they were very happy with the care provided by their dentist. One person said, "I wouldn't have come here for so many years if I wasn't happy." Another said, "I am happy, always treated with courtesy and the staff are all very polite."

People told us that they were involved in the decision making associated with their treatment and had received clear explanations about the treatment, costs and aftercare before being asked to consent in writing Those we spoke with had all been asked to provide a medical history prior to treatment and stated they would be happy recommend the practice to friends and relatives.

We found that infection control procedures were not always being carried out to a satisfactory standard and that staff were not supported in relation to regular supervision and annual appraisals.

We also found that there were insufficient processes in place for monitoring the quality of service provided due to an absence of a variety of audits and service user surveys.