We carried out an announced comprehensive inspection of this service on 13 April 2016 as part of our regulatory functions where two breaches of legal requirements were found.

After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach.

We followed up on our inspection of 29 June 2016 to check that the practice had followed their plan and to confirm that they now met the legal requirements. This report only covers our findings in relation to those requirements.

We revisited Wembley High Street Dental Surgery as part of this review. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Wembly High Street Dental Surgery on our website at www.cqc.org.uk.

We carried out an announced comprehensive inspection on 13 April 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 not 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

Wembley High Street Dental Practice is located in the London Borough of Brent and provides mainly private, but also NHS dental treatment to both adults and children. The premises are on the first floor above retail premises and consist of two treatment rooms and a reception area. The practice is open on Monday - Friday 9:00am – 5:00pm.

The staff consists of the principal dentist, one associate dentist, a trainee dental nurse, a dental hygienist and a dental nurse who is also the receptionist.

The principal dentist is registered with the Care Quality Commission (CQC) as an individual. 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 reviewed twenty nine CQC comment cards. Patients were positive about the service. They were complimentary about the friendly and caring attitude of the staff.

The inspection took place over one day and was carried out by a CQC inspector and a dental specialist advisor

Our key findings were:

• There were appropriate equipment and access to emergency drugs to enable the practice to respond to medical emergencies. Staff knew where equipment was stored.

• Patients had good access to appointments including emergency appointments.

• We observed staff to be caring, friendly, reassuring and welcoming to patients.

• Patients indicated that they found the team to be efficient, professional, caring and reassuring.

• There was lack of appropriate systems in place to safeguard patients.

• There was a lack of effective arrangements in place to meet the Control of Substances Hazardous to Health 2002 (COSHH) Regulations.

• Staff did not receive appropriate support and appraisal as is necessary to enable them to carry out the

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  duties.

• There was a lack of an effective system to assess, monitor and improve the quality and safety of the services provided.

• There was a lack of an effective system to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients, staff and visitors.

• Governance arrangements in place were not effective to facilitate the smooth running of the service and there was no evidence of audits being used for continuous improvements.

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

• Ensure that the practice has and implements, robust procedures and processes that make sure that people are protected.

• Ensure the practice's recruitment policy and procedures are suitable and the recruitment arrangements are in line with Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 to ensure necessary employment checks are in place for all staff and the required specified information in respect of persons employed by the practice is held.

• Ensure the practice’s infection control procedures and protocols are suitable giving due regard to guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’.

• Ensure that the practice is in compliance with its legal obligations under Ionising Radiation Regulations (IRR) 99 and Ionising Radiation (Medical Exposure) Regulation (IRMER) 2000.

• Ensure the training, learning and development needs of individual staff members are reviewed at appropriate intervals and an effective process is established for the on-going assessment and supervision of all staff.

• Ensure audits of various aspects of the service, such as radiography, infection control and dental care records are undertaken at regular intervals to help improve the quality of service. The practice should also check all audits have documented learning points and the resulting improvements can be demonstrated.

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

• Ensure processes and systems are put in place for seeking and learning from feedback from patients, staff and others with a view to monitoring and improving the quality of the service.

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

• 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 protocols for the use of rubber dam for root canal treatment giving due regard to guidelines issued by the British Endodontic Society.

• Review the practice's protocols for medicines management and ensure all medicines are stored safely and securely.

• 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 giving due regard to the Ionising Radiation (Medical Exposure) Regulations (IRMER) 2000.

• 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 its complaint handling procedures and establish an accessible system for identifying, receiving, recording, handling and responding to complaints by patients.

• 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 storage of records related to people employed and the management of regulated activities giving due regard to current legislation and guidance.