We carried out this announced inspection on 3 May 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We previously carried out an inspection in January 2016 and the purpose of this inspection was to also follow up on the two requirement notices served for good governance and staffing. 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.

We carried out a comprehensive inspection at this service on the 19 January 2016 where we found breaches of our regulations in Regulation 17 good governance and Regulation 18 staffing and requirement notices were served. The main areas of concern highlighted were; infection control, staff support, fire safety and clinical audit.

We told the NHS England area team and Healthwatch that we were inspecting the practice. They did not provide any information.

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

Yeovil Dental Practice is in Yeovil, Somerset and provides approximately 80% NHS and 20% private treatment to patients of all ages.

The practice is a listed building with uneven levels and narrow staircases. The front entrance is not accessible for wheelchair users and so there is an access lift outside the building and a concrete ramp for disabled access into the back of the building. There are also two accessible spacious surgeries on the ground floor. There is a small car park with limited spaces with one disabled parking bay. There are local public car parks and transport nearby.

The dental team includes five dentists, two trained dental nurses (one of which is the practice manager), seven trainee dental nurses, one dental hygienist and two receptionists. The practice has five treatment rooms.

The practice is owned by a Rodericks Dental Limited 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. At the time of the inspection the practice did not have a registered manager in post.

On the day of inspection we collected six CQC comment cards filled in by patients and spoke with four other patients. This information gave us a positive view of the practice.

During the inspection we spoke with all five dentists, six dental nurses and two receptionists, the practice manager and area manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

• Monday, Wednesday and Friday 8:30am to 5pm
• Tuesday and Thursday 8:30am to 7pm
• The first Saturday of each month from 9am to 12pm

Our key findings were:

• The practice appeared clean and well maintained.
• The practice had infection control procedures which reflected published guidance. However, they still needed to ensure they had adequate ventilation in the decontamination room.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment was available.
• The practice had systems to help them manage risk, such as fire safety, health and safety and legionella.
• The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
• 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 appointment system met patients’ needs.
• The practice had effective leadership and management. Staff felt involved, well supported and worked well as a team.
• The practice asked staff and patients for feedback about the services they provided.
• The practice dealt with complaints positively and efficiently.
• The practice had adequate staff recruitment procedures. Risk assessments had not always been undertaken when key documentation, such as references had not been received prior to commencement of the staff member’s employment.
• Policies and procedures needed improvement to be reflective of localised procedures and current legislation.

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

• Review the security of prescription pads in the practice and ensure there are systems in place to monitor and track their use.
• Review the practice's recruitment policy and procedures to ensure accurate, complete and detailed records are maintained for all staff.

We carried out an unannounced comprehensive inspection on 19 January 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 this practice was not 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

Yeovil Dental Practice is centrally located close to the town centre and is an old character building with uneven levels and narrow staircases in places. It has five surgeries which are used by four dentists and a hygienist. It provides general dentistry, including endodontics and restorative services, to NHS patients, but will also treat private patients. There is car parking at the side of the practice and local public car parks near-by. Provision has been made for wheelchair access to the two downstairs surgeries.

The practice had four dentists and a hygienist who were supported by eight trainee dental nurses / receptionists and a practice manager. There was no registered manager at the practice. 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.

The practice is open Monday & Wednesday, 08.15am to 5.15pm; Tuesday & Thursday 08.15am – 7.15pm; Friday 08.15 – 1.15pm. The practice is closed at weekends.

We spoke with six patients during the inspection and asked about their experience of the services provided. Feedback from patients was positive about the care they received from the practice. They commented staff put them at ease, listened to their concerns and they had confidence in the dental services provided.

Our key findings were:

• The practice carried out oral health assessments and planned treatment in line with current best practice guidance, for example from the Faculty of General Dental Practice (FGDP). Patient dental care records were detailed and showed on-going monitoring of patients oral health.
• The practice was not meeting the Essential Quality Requirements of the Department of Health guidance, namely 'Health Technical Memorandum 01-05 - Decontamination in primary care dental practices (HTM 01-05)' national guidance for infection prevention control in dental practices. There was no clear designated lead professional for infection prevention and control.
• The management of sharps was not in accordance with the current EU regulations with respect to safer sharps (Health and Safety Sharp instruments in Healthcare Regulations 2013).
• Dentists maintained their continuing professional development and had undertaken training appropriate to their roles. However they did not feel well supported in their work. There were limited records to evidence monitoring of trainee dental nurses.
• Equipment, such as the air compressor, autoclave (steriliser), fire extinguishers, and X-ray equipment had been checked for effectiveness and serviced.
• Patients commented they felt involved in their treatment and that it was fully explained to them. We spoke with six patients who told us they felt that they received very good care in a clean environment from a helpful practice team.

• The practice had an efficient appointment system in place to respond to patient’s needs. Patients were able to make routine and emergency appointments when needed. There were clear instructions for patients regarding out of hours care.
• The practice had effective safeguarding processes in place and staff understood their responsibilities for safeguarding adults and children living in vulnerable circumstances.
• Staff knew how to report incidents and how to record details of these so that the practice could use this information for shared learning.
• There was no evidence the results of recent audits had been reviewed and an action plan implemented to address issues identified.

• The practice had an accessible and visible manager with means of sharing information with staff.

There were areas where the provider must make improvements and must:

• Ensure an effective system is established to assess, monitor and mitigate the various risks arising from undertaking of the regulated activities in a timely way.
• Ensure the practice fully meets the Essential Quality Requirements of the Department of Health guidance, namely 'Health Technical Memorandum 01-05 - Decontamination in primary care dental practices (HTM 01-05)' as soon as is practically possible.
• Provide training and competency assessment for staff about infection prevention and control and ensure all processes adhere to the national guidance HTM 01-05.
• Ensure dental sharps are managed in accordance with the current Health and Safety Sharp instruments in Healthcare Regulations 2013 and staff are appropriately trained.
• Ensure appropriate systems are in place to meet health and safety regulations including risk assessment.

• Plan and implement a system of audit as soon as practically possible for infection control dental X-rays and other such audits as expected by the General Dental Council standards and as advised by the Faculty of General Dental Practice.

• Provide and support good governance of the practice and assess service delivery to ensure quality, patient centred treatment and care, supported by learning and innovation, and promote an open culture.

People that we spoke with on the day of our visit told us that treatment options were explained and that they were aware of the cost of their treatment. We were told that staff were friendly and helpful and that appointments were easy to make. People confirmed that their medical histories were taken before commencement of treatment, and that they were updated at each check-up appointment. One patient told us that they were very happy with the service provided, that the staff were friendly and that they would definitely recommend to others.

We also looked at patient feedback gathered through surveys and comment forms and noted a number of positive comments. These included "the dentist and the dental nurse were great with the children" and "the dentist is lovely".