Passage House Dental Care

We undertook a focused inspection of Passage House Dental Practice on 11 February 2020. 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 who was supported by a specialist dental adviser.

We undertook a comprehensive inspection of Passage House Dental Practice on 19 June 2019 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 19 fit and proper persons employed 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 Passage House Dental Care 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 area where improvement was required.

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 breach we found at our inspection on 19 June 2019.

Background

Passage House Dental Care is in Henbury, Bristol and provides NHS and private treatment for adults and children.

There is level access for people who use wheelchairs and those with pushchairs. There are two patient car parking spaces, which are available, at the front of the practice. There is also one hour’s parking available near the practice.

The dental team includes seven dentists, eight dental nurses, one dental hygienist and four receptionists and a practice manager. The practice has five treatment rooms.

The practice is owned by a partnership 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 Passage House Dental Care is the senior partner.

During the inspection we spoke with the registered manager and the practice manager. We looked at practice policies and procedures and other records about how the service is managed in relation to the breach of regulation and areas where we told the provider they should improve upon the last inspection.

The practice is open:

• Monday 8:30am – 5:30pm
• Tuesday 8:30am – 6:30pm
• Wednesday 8:30am – 5pm
• Thursday 8am – 5:30pm
• Friday 8am – 4pm

Our key findings were:

• Effective systems were in place to ensure all information specified within schedule 3 of the Health and Social Care Act 2008 (regulated activities) was in place for recruited staff.
• The provider had addressed the outstanding action for the use of X-ray equipment.
• The outstanding risks had been mitigated in regards to fire safety.
• NHS prescriptions were held securely and monitored for their use.
• An audit had been completed for prescribing antibiotic medicines, which took into account the guidance provided by the Faculty of General Dental Practice.
• Patient referrals to other dental or health care professionals were centrally monitored to ensure they were received within a timely manner and not lost.

We carried out this announced inspection on 19 June 2019 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 not providing well-led care in accordance with the relevant regulations.

Background

Passage House Dental Care is based in Henbury, Bristol and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. There are two patient car parking spaces which are available at the front of the practice. There is parking available for an hour at a time nearby.

The dental team includes seven dentists including a consultant orthodontist, eight dental nurses, one dental hygienist, a practice manager, four receptionists and a cleaner. The practice has five treatment rooms.

The practice is owned by a partnership 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 Passage House Dental Care is the senior partner.

On the day of inspection, we collected 16 CQC comment cards filled in by patients and spoke with four other patients.

During the inspection we spoke with four dentists, three dental nurses, two receptionists 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 8:30am-5:30pm

Tuesday 8:30am-6:30pm

Wednesday 8:30am-5pm

Thursday 8am-5:30pm

Friday 8am-4pm

Our key findings were:

• The practice appeared clean and well maintained.
• The provider had infection control procedures which reflected published guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
• The practice had systems to help them manage risk to patients and staff. Although some areas could be improved including fire safety, antibiotic prescribing, sedation and radiation.
• The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The provider had staff recruitment procedures, which should be improved upon.
• 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.
• Staff were providing preventive care and supporting patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• The provider leadership could be improved to ensure it met with regulations to continuously improve its practice.
• Staff felt involved and supported and worked well as a team.
• The provider 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:

• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

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:

• Review the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and 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 systems for assessing, monitoring and mitigating the various risks arising from the undertaking of the regulated activities. In particular for fire safety.
• Review the security of NHS prescription pads in the practice and ensure the systems in place to monitor their use are effective.
• Review the practice protocols regarding audits for prescribing of antibiotic medicines taking into account the guidance provided by the Faculty of General Dental Practice.
• Review the practice's procedures to ensure patient referrals to other dental or health care professionals are received in a timely manner.
• Review the practice’s protocols for conscious sedation, taking into account the guidelines published by The Intercollegiate Advisory Committee on Sedation in Dentistry in the document 'Standards for Conscious Sedation in the Provision of Dental Care 2015.