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Inspection Summary


Overall summary & rating

Updated 25 June 2021

We carried out this announced inspection on 2 June 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 always ask the following five questions:

• Is it safe?

• Is it effective?

• 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 this practice was 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 well-led?

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

Background

183 Dental is in the Whiston area of Merseyside and provides NHS dental care to children and private dental care and treatment for adults and children.

There is stepped access to the practice and for people who use wheelchairs and those with pushchairs, a portable ramp is available on request. Car parking spaces are available near the practice. The parking areas immediately outside the practice are subject to restricted waiting times.

The dental team includes two dentists, two dental nurses, a dental hygiene therapist, a receptionist, and a dental nurse/practice manager. The practice has two treatment rooms.

The practice is owned by a company and as a condition of registration must have a person registered with the CQC 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 183 Dental is one of the principal dentists.

During the inspection we spoke with two dentists, two dental nurses, 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 9am to 5.30pm and by appointment only, based on demand, on Saturday from 10am to 2pm.

Our key findings were:

  • The practice appeared to be visibly clean and well-maintained. We noted that the electrical certificate held was for remedial works carried out at the practice in 2017, ahead of the purchase of the practice by the current provider. We drew attention to this on the day of inspection.
  • 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 provider had systems to help them manage risk to patients and staff.
  • The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • The provider had staff recruitment procedures which reflected current legislation.
  • 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 appointment system took account of patients’ needs.
  • The provider had effective leadership and a culture of continuous improvement.
  • Staff felt involved and supported and worked 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 information governance arrangements.

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

  • Implement an effective system of checks of medical emergency equipment and medicines taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.
  • Take action to ensure the suitability of the premises and ensure all areas are fit for the purpose for which they are being used. In particular, ensure all electrical installations are inspected within the required frequency to ensure electrics within the building are adequately maintained and meet all required safety standards.

Inspection areas

Safe

No action required

Updated 25 June 2021

We found 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 had received safeguarding training. 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 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 arrangements for transporting, cleaning, checking, sterilising and storing instruments in line with HTM 01-05. The records showed equipment used by staff for cleaning and sterilising instruments was validated, maintained and used in line with the manufacturers’ guidance. The provider had suitable numbers of dental instruments available for the clinical staff and measures were in place to ensure they were decontaminated and sterilised appropriately.

The staff carried out manual cleaning of dental instruments prior to them being sterilised. We advised the provider that manual cleaning is the least effective recognised cleaning method as it is the hardest to validate and carries an increased risk of an injury from a sharp instrument.

The staff had systems in place to ensure that patient-specific dental appliances were 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 in the assessment had been actioned and records of water testing and dental unit water line management were maintained.

We saw effective cleaning schedules to ensure the practice was kept clean. When we inspected we saw the practice was visibly clean. Standard operating procedures had been developed and introduced during the pandemic, to reduce risks posed by COVID 19. All arrangements to support COVID security were reviewed and refined by leaders, to ensure the health, safety and welfare of staff and patients visiting the practice.

The provider had policies and procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance.

The infection control lead carried out infection prevention and control audits twice a year. The latest audit showed the practice was meeting the required standards.

The practice’s speaking up policies were in line with the NHS Improvement Raising Concerns (Whistleblowing) Policy. The staff felt confident they could raise concerns without fear of recrimination.

The dentists used dental dam in line with guidance from the British Endodontic Society when providing root canal treatment. In instances where 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 two full staff recruitment records. These showed the provider followed their recruitment procedure.

We observed that clinical staff were qualified and registered with the General Dental Council and had professional indemnity cover.

We checked how staff ensured facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions, including electrical and gas appliances. We observed the wiring to the hot water cylinder on the first floor was aged; the cupboard housing the hot water cylinder was also filled with other items, such as cardboard boxes, manuals, and other materials. When we checked, we noted the electrical safety certificate held for the practice was in fact a certificate for remedial works carried out by the previous provider, ahead of purchase of the practice by the current provider. Works carried out were in response to an electrical inspection report stating the electrical installation was ‘unsatisfactory’. The provider did not provide documentation that confirmed that the fixed electrical wiring installation at the practice was safe.

A fire risk assessment was carried out by the practice owners. We saw there were fire extinguishers and fire detection systems throughout the building and fire exits were kept clear.

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

We saw evidence the dentists 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 in respect of dental radiography.

Risks to patients

The provider had implemented systems to assess, monitor and manage risks to patient safety.

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

The provider had a system in place to ensure clinical staff had received appropriate vaccinations, including vaccination to protect them against the Hepatitis B virus, and that the effectiveness of the vaccination was checked.

Staff had completed sepsis awareness training. Sepsis prompts for staff and patient information posters were displayed throughout the practice. This helped ensure staff made triage appointments effectively to manage patients who present with dental infection and where necessary refer patients for specialist care

Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

Emergency equipment and medicines were largely available as described in recognised guidance. When checking through all equipment we observed that a self-inflating bag with reservoir in child size was missing, and clear face masks for the self-inflating bag in all required sizes (0, 1, 2, 3, 4) were not present. The provider confirmed on the day of inspection they would order these items. We found staff kept records of their checks of these to make sure they were available, within their expiry date, and in working order. However these checks had failed to identify the missing items from the emergency equipment. We drew this to the attention of staff making these checks and to the provider on the day of our inspection.

A dental nurse worked with the dentists and the dental hygiene therapists when they treated patients in line with General Dental Council Standards for the Dental Team.

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

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 dentist 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 or typed 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 NHS prescriptions as described in current guidance.

The dentists were aware of current guidance with regards to prescribing medicines.

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 implemented systems for reviewing and investigating when things went wrong. There were comprehensive risk assessments in relation to safety issues. Staff monitored and reviewed incidents. This helped staff to understand risks which led to effective risk management systems in the practice as well as safety improvements.

Where there had been a safety incident we saw this was investigated, documented and discussed with the rest of the dental practice team to prevent such occurrences happening again.

The provider had a system for receiving and acting on safety alerts. Staff learned from external safety events as well as patient and medicine safety alerts. We saw they were shared with the team and acted upon if required.

Effective

No action required

Updated 25 June 2021

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

Effective needs assessment, care and treatment

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

Helping patients to live healthier lives

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

The dentists prescribed high concentration fluoride products if a patient’s risk of tooth decay indicated this would help them.

The dentists where applicable, discussed smoking, alcohol consumption and diet with patients during appointments. The practice had a selection of dental products for sale and provided leaflets to help patients with their oral health.

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

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

Consent to care and treatment

Staff 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 staff were aware of the need to obtain proof of legal guardianship or Power of Attorney for patients who lacked capacity or for children who are looked after. The dentists 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. Patients confirmed their dentist listened to them and gave them clear information about their treatment.

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 may 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 dentists 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 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 dentists confirmed they referred patients to a range of specialists in primary and secondary care for treatment the practice did not provide.

Caring

Updated 25 June 2021

Responsive

Updated 25 June 2021

Well-led

No action required

Updated 25 June 2021

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

Leadership capacity and capability

We found leaders had the capacity, values and skills to deliver high-quality, sustainable care.

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

The provider had a strategy for delivering the service which was in line with health and social priorities across the region. Staff planned the services to meet the needs of the practice population.

Culture

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

Staff discussed their training needs at an annual appraisal and during 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.

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

Staff had clear responsibilities, roles and systems of accountability to support good governance and management.

The principal dentist who is the registered manager had overall responsibility for the management and clinical leadership of the practice. The recently recruited practice 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.

Appropriate and accurate information

Staff acted on appropriate and accurate information.

Quality and operational information, for example audits were used to ensure and improve performance. Performance information was combined with the views of patients.

The provider had information governance arrangements and staff were aware of the importance of these in protecting patients’ personal information.

Engagement with patients, the public, staff and external partners

Staff involved patients, staff and external partners to support the service.

The provider listened to patient feedback and patients’ views about the service. We saw examples of suggestions the practice had acted on. For example, the option to offer appointments to some patients on Saturdays, in accordance with demand.

The provider gathered feedback from staff through meetings and informal discussions. Staff were encouraged to offer suggestions for improvements to the service and said these were listened to and acted on.

Continuous improvement and innovation

The provider had systems and processes for learning, continuous improvement and innovation.

The provider had quality assurance processes to encourage learning and continuous improvement. These included audits of dental care records, radiographs and infection prevention and control. Staff kept records of the results of these audits and the resulting action plans and improvements.

The principal dentists 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. The provider supported and encouraged staff to complete continuing professional development.