You are here

Inspection Summary


Overall summary & rating

Updated 29 September 2021

We carried out this announced inspection on 15 September 2021 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 Care Quality Commission (CQC) inspector who was supported by a specialist dental adviser.

To get to the heart of patients’ experiences of care and treatment, we usually ask five key questions. However, due to the ongoing pandemic and to reduce time spent on site, only the following three questions were asked:

• Is it safe?

• Is it effective?

• Is it well-led?

These are three of the five questions that 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 well-led?

We found that this practice was providing well-led care in accordance with the relevant regulations.

Background

Bow Lane Limited is in the City of London and provides private general and specialist dental treatment to adults and children. Specialist services available at the practice include conscious sedation, dental implants, endodontics and orthodontics.

The practice is arranged over four floors of a building close to Bank underground station. The practice does not have step free access. Patients requiring ground floor treatment rooms are signposted to another local practice that can offer this. Bow Lane Limited has six treatment rooms, alongside a separate decontamination room and dental laboratory on the top floor.

The team consists of six dentists, a specialist orthodontist, a specialist endodontist, two dental hygienists, a dental hygiene therapist, four dental nurses, a decontamination technician, an orthodontic therapist, a business manager, two receptionists and two administrators.

The practice is owned by an organisation 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 Bow Lane Limited is the principal dentist.

During the inspection we spoke with the principal dentist, the business manager and four dental nurses. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open to patients:

Monday, Tuesday and Thursday from 7.45am to 5.30pm.

Wednesday from 8.30am to 5.30pm.

Friday from 8am to 5pm.

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 was available.
  • The provider had systems to help them manage risk to patients and staff.
  • The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • The provider had thorough staff recruitment procedures.
  • 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 provided preventive care and supported patients to ensure better oral health.
  • The provider had effective leadership and culture of continuous improvement.
  • 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 had suitable information governance arrangements.
Inspection areas

Safe

No action required

Updated 29 September 2021

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

Safety systems and processes, including staff recruitment, equipment and premises and radiography (X-rays)

Staff had clear systems to keep patients safe.

Staff knew their responsibilities if they had concerns about the safety of children, young people and adults who were vulnerable due to their circumstances. The provider had safeguarding policies and procedures to provide staff with information about identifying, reporting and dealing with suspected abuse. We saw evidence that staff received safeguarding training and undertook scenario sessions in team meetings. Staff knew about the signs and symptoms of abuse and neglect and how to report concerns, including notification to the CQC.

The provider had a system to highlight vulnerable patients and patients who required other support such as with mobility or communication within dental care records.

The provider also had a system to identify adults that were in other vulnerable situations, for example those who were known to have experienced modern-day slavery or female genital mutilation.

The provider had a whistleblowing policy. Staff felt confident they could raise concerns without fear of recrimination.

The provider used dental dams in line with guidance from the British Endodontic Society when providing root canal treatment. In instances where the dental dam was not used, such as for example refusal by the patient, and where other methods were used to protect the airway, we saw this was documented in the dental care record and a risk assessment completed.

The provider had a recruitment policy and procedure to help them employ suitable staff and had checks in place for agency and locum staff. These reflected the relevant legislation. We looked at three recruitment records. These showed the provider followed their recruitment procedure.

We noted that the provider was qualified and registered with the General Dental Council (GDC) and had professional indemnity cover.

Staff ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions, including electrical appliances.

Records showed that fire detection and firefighting equipment were regularly tested and serviced.

The practice had suitable arrangements to ensure the safety of the X-ray equipment and we saw the required information was in their radiation protection file.

We saw evidence that the provider justified, graded and reported on the radiographs they took. The provider carried out radiography audits every year following current guidance and legislation.

Clinical staff completed continuing professional development (CPD) in respect of dental radiography.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

The provider’s health and safety policies, procedures and risk assessments were reviewed regularly to help manage potential risk. The provider had current employer’s liability insurance.

We looked at the provider’s arrangements for safe dental care and treatment. The staff followed relevant safety regulation when using needles and other sharp dental items. A sharps’ risk assessment had been undertaken and was updated annually.

The dental team had received the vaccinations required to protect them against the hepatitis B virus and ensured that the effectiveness of the vaccination was checked.

Staff knew how to respond to a medical emergency and completed training in emergency resuscitation and basic life support every year. Immediate life support training with airway management for staff providing treatment under sedation was also completed.

Emergency equipment and medicines were available as described in recognised guidance. We found staff kept records of their checks of these to make sure they were available, within their expiry date, and in working order.

A dental nurse worked with the dentists when they treated patients in line with General Dental Council (GDC) Standards for the Dental Team.

The provider had suitable risk assessments to minimise the risk that can be caused from substances that are hazardous to health.

The provider had an infection prevention and control policy and procedures. They followed guidance in The Health Technical Memorandum 01-05: Decontamination in primary care dental practices (HTM 01-05) published by the Department of Health and Social Care. Staff completed infection prevention and control training and received updates as required.

The provider had a policy in place which outlined the actions taken to protect staff and the public from the spread of COVID-19. The provider had taken measures to ensure the safe reopening of the practice following its closure in 2020. The principal dentist had received training in fit testing required for the safe use of Filtering Face Piece masks.


The provider had suitable arrangements for transporting, cleaning, checking, sterilising and storing instruments in line with HTM 01-05 guidance. The records showed equipment used by staff for cleaning and sterilising instruments was validated, maintained and used in line with the manufacturers’ guidance.


We found staff had systems in place to ensure that any work was disinfected prior to being sent to a dental laboratory and before treatment was completed.


We saw staff had procedures to reduce the possibility of legionella or other bacteria developing in the water systems, in line with a risk assessment. All recommendations had been actioned and records of water testing and dental unit water line management were in place.


We saw cleaning schedules for the premises. The practice was visibly clean when we inspected. The provider had policies and procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance. The provider carried out infection prevention and control audits twice a year in line with national guidance.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

We discussed with the provider how information to deliver safe care and treatment was handled and recorded. We looked at dental care records with clinicians to confirm our findings and observed that individual records were written and managed in a way that kept patients safe. Dental care records we saw were complete, legible, were kept securely and complied with General Data Protection Regulation requirements.

The provider had systems for referring patients with suspected oral cancer under the national two-week wait arrangements. These arrangements were initiated by National Institute for Health and Care Excellence to help make sure patients were seen quickly by a specialist.

Safe and appropriate use of medicines

The provider had systems for appropriate and safe handling of medicines.

There was a stock control system of medicines which were held on site. This ensured that medicines did not pass their expiry date and enough medicines were available if required.

We saw staff stored and kept records of prescriptions as described in current guidance. Antimicrobial prescribing audits were carried out annually. The most recent audit indicated the dentists were following current guidelines.

Track record on safety and lessons learned and improvements

The provider had a clear system in place to deal with significant events and near misses.

The provider held the correct numbers for who to contact with any safety issues in the practice.

The provider had policies and procedures for receiving and acting on safety alerts. Relevant alerts were stored on the computer and shared appropriately.

Effective

No action required

Updated 29 September 2021

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

Effective needs assessment, care and treatment

The practice had systems to keep the dentists up to date with current evidence-based practice. We saw that the provider assessed patients’ needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

The practice offered conscious sedation for patients. This included patients who were very anxious about dental treatment and those who needed complex or lengthy treatment. The practice had systems to help them do this safely. These were in accordance with guidelines published by the Royal College of Surgeons and Royal College of Anaesthetists in 2015.

The practice’s systems included checks before and after treatment, emergency equipment requirements, medicines management, sedation equipment checks, and staff availability and training. They also included patient checks and information such as consent, monitoring during treatment, discharge and post-operative instructions.

The staff assessed patients for sedation. The dental care records showed that patients having sedation had important checks carried out first. These included a detailed medical history’ blood pressure checks and an assessment of health using the guidance. The records also showed that staff recorded details of the concentrations of the sedation gases used.

The operator-sedationist was supported by a trained second individual. The name of this individual was recorded in the patients’ dental care record.

The orthodontist carried out a patient assessment in line with recognised guidance from the British Orthodontic Society. An Index of Orthodontic Treatment Need was recorded which would be used to determine whether a patient was eligible for NHS orthodontic treatment. The patient’s oral hygiene was also assessed to determine if the patient was suitable for orthodontic treatment.

The practice offered dental implants. These were placed by one of the dentists at the practice who had undergone appropriate post-graduate training in the provision of dental implants. We saw the provision of dental implants was in accordance with national guidance.

Staff had access to intra-oral cameras to enhance the delivery of care. One of the dentists had an interest in endodontics (root canal treatment). The dentist used a specialised operating microscope to assist in carrying out root canal treatment. The dentist also provided advice and guidance on endodontics to the other dentists in the practice.


Helping patients to live healthier lives



The practice was providing preventive care and supporting patients to ensure better oral health in line with the Delivering Better Oral Health toolkit.

The dentists prescribed high concentration fluoride toothpaste if a patient’s risk of tooth decay indicated this would help them. They used fluoride varnish for patients based on an assessment of the risk of tooth decay.

The practice had a selection of dental products for sale and provided health promotion leaflets to help patients with their oral health.

Staff were aware of national oral health campaigns and local schemes in supporting patients to live healthier lives. For example, local stop smoking services. They directed patients to these schemes when necessary.

The provider was committed to improving public health through education. Members of the practice team regularly visited nurseries, schools and libraries to offer free advice, check-ups and dental products for children. The provider offered a holistic service, ensuring each patient contact included a conversation about many determinants of health; including diet, exercise and lifestyle. The provider was also the founder of a charity aimed at transforming the way we reward children, and had worked with over 500 schools and nurseries to remove sugar from their food options.

The principal dentist described to us the procedures they used to improve the outcomes for patients with gum disease. This involved providing patients preventative advice, taking plaque and gum bleeding scores and recording detailed charts of the patient’s gum condition.

Records showed patients with more severe gum disease were recalled at more frequent intervals for review and to reinforce home care preventative advice.

The practice carried out detailed oral health assessments which identified a patient’s individual risks. Patients were provided with detailed self-care treatment plans with dates for ongoing oral health reviews based upon their individual need and in line with recognised guidance.

Consent to care and treatment

The dentists obtained consent to care and treatment in line with legislation and guidance.

The practice team understood the importance of obtaining and recording patients’ consent to treatment. The provider gave patients information about treatment options and the risks and benefits of these, so they could make informed decisions. We saw this documented in patients’ records.

The practice’s consent policy included information about the Mental Capacity Act 2005. The team understood their responsibilities under the act when treating adults who might not be able to make informed decisions. The policy also referred to Gillick competence, by which a child under the age of 16 years of age might give consent for themselves in certain circumstances. Staff were aware of the need to consider this when treating young people under 16 years of age.

Staff described how they involved patients’ relatives or carers when appropriate and made sure they had enough time to explain treatment options clearly.

Monitoring care and treatment

The practice kept detailed dental care records containing information about the patients’ current dental needs, past treatment and medical histories. The provider assessed patients’ treatment needs in line with recognised guidance.

The provider had quality assurance processes to encourage learning and continuous improvement. Staff kept records of the results of these audits, the resulting action plans and improvements.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

Staff new to the practice, including agency staff, had a structured induction programme. We confirmed clinical staff completed the continuing professional development required for their registration with the General Dental Council.

Co-ordinating care and treatment

Staff worked together and with other health and social care professionals to deliver effective care and treatment.

The provider confirmed they referred patients to a range of specialists in primary and secondary care for treatment the practice did not provide. The provider held a log of referrals made to other specialists.

Caring

Updated 29 September 2021

Responsive

Updated 29 September 2021

Well-led

No action required

Updated 29 September 2021

We found that this practice was providing well-led care in accordance with the relevant regulations.

The provider demonstrated a transparent and open culture in relation to people’s safety. There was strong leadership and emphasis on continually striving to improve. Systems and processes were embedded, and staff worked together in such a way that the inspection did not highlight any issues or omissions. The information and evidence presented during the inspection process was clear and well documented. They could show how they sustain high-quality sustainable services and demonstrate improvements over time.

Leadership capacity and capability

We found the senior leadership team had the capacity and skills to deliver high-quality, sustainable care. The members of senior leadership team demonstrated that they had the experience, capacity and skills to deliver the practice strategy and address risks to it.

Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.

Leaders at all levels were visible and approachable. Staff told us they worked closely with them and others to make sure they prioritised compassionate and inclusive leadership.

We saw the provider had effective processes to develop leadership capacity and skills, including planning for the future of the practice.

Culture

The practice had a culture of high-quality sustainable care.

Staff stated they felt respected, supported and valued. They were proud to work in the practice.

Staff discussed their training needs at an annual appraisals and regular meetings. They also discussed learning needs, general wellbeing and aims for future professional development. We saw evidence of completed appraisals in the staff folders.

The staff focused on the needs of patients. For example, anxious patients were offered therapies such as hypnosis and acupuncture. The staff also offered to meet patients at the underground station and walk with them to the practice, to provide reassurance and ease any anxiety.

We saw the provider had systems in place to deal with staff poor performance.

Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the Duty of Candour.

Staff could raise concerns and were encouraged to do so, and they had confidence that these would be addressed.

Governance and management

There were clear responsibilities, roles and systems of accountability to support good governance and management.

The principal dentist had overall responsibility for the management and clinical leadership of the practice. The business manager was responsible for the day to day running of the service. Staff knew the management arrangements and their roles and responsibilities.

The provider had a system of clinical governance in place which included policies, protocols and procedures that were accessible to all members of staff and were reviewed on a regular basis.

Engagement with patients, the public, staff and external partners


The provider involved patients to support high-quality sustainable services.

The provider used patient surveys, internet-based reviews and verbal feedback to obtain patients’ views about the service. They monitored the feedback and continually received positive comments each month. Online reviews stated that many patients felt the provider gave an excellent service.

The principal dentist and business manager spent time obtaining feedback from staff and ensuring their wellbeing. The team enjoyed regular social events and team building days.

The provider had developed a corporate social responsibility programme that practice staff and patients had become involved with. A charity committee held meetings each month to work on fundraising projects for both local and international charities. Staff we spoke with described the commitment had increased their confidence and fulfilment within the workplace. Fundraising and volunteering work had been undertaken to train two members of the public in Tanzania to become emergency dental care workers. Furthermore, members of the clinical team devoted time to providing free dental treatment to military veterans requiring care.

The provider was committed to minimising their impact on the environment and running a sustainable business. The provider had replaced as many items as possible with sustainable alternatives and promoted their use to patients. A recycling station for dental products was available for patients and members of the public to use.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation. These included audits of dental care records, disability access, dental radiographs and infection prevention and control.

The provider showed a commitment to learning and improvement and valued the contributions made to the team by individual members of staff.

Staff completed ‘highly recommended’ training as per General Dental Council professional standards. This included undertaking medical emergencies and basic life support training annually. The provider supported and encouraged staff to complete CPD. The provider paid for all internal and external staff training, such as customer service, radiography and oral health care.

During the pandemic the principal dentist had shown innovation in the use of technology to enhance the care for patients. They had produced ‘How to’ videos which were published on the practice’s website and social media platforms to help patients during the time when they were closed to patients. Furthermore, the principal dentist had produced multiple free online seminars for dental professionals to access during the lockdown period, with topics including diet and nutrition, engaging with patients about public health, and re-emerging from practice closure.