We carried out an unannounced comprehensive inspection on 14 November 2016 in response to concerns that were reported to CQC about the essential standards of quality and safety that were not being met. We asked 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 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
Vicarage Lane is a dental practice providing NHS and private treatment for both adults and children. The practice is located in a residential area in commercial premises in Surrey.
The practice is based at ground floor level and is accessible to wheelchair users, prams and patients with limited mobility. The practice has four dental treatment rooms and a separate decontamination room used for cleaning, sterilising and packing dental instruments.
The practice employs two dentists, one hygienist, two dental nurses of which one is a trainee, one receptionist and a practice manager. The practice manager was on maternity leave and therefore a temporary practice manager had been in post until recently. The temporary practice manager had left the practice within the last week.
The practice’s opening hours are 8.45am to 1pm and 2pm to 5.45pm Monday, Tuesday and Thursday, 8.45am to 1pm and 2pm to 6.45pm on Wednesday, 8.45am to 1pm and 2pm to 5pm Friday and 8.45am and 1pm on Saturday.
There are arrangements in place to ensure patients receive urgent medical assistance when the practice is closed. This is provided by an out-of-hours service.
The registered manager at the time of our inspection was the practice manager and was on maternity leave. 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.
We obtained the views of four patients on the day of our inspection. They spoke positively about their experience of the care they received at the practice. They commented that dental treatment was explained to them prior to any treatment being provided. They also mentioned that they had good access to appointments if they were in pain.
Our key findings were:
- Medicines and life-saving equipment was available in accordance with current guidelines but we found that two emergency medicines had passed their expiry date and the storage container of one emergency medicine had a broken seal potentially affecting their effectiveness.
- The practice appeared visibly clean and well maintained.
- Generally, there was appropriate equipment for staff to undertake their duties however staff reported that several items of equipment were broken. Although these issues were raised through the practice manager within the company, staff reported that these issues had not been addressed in a timely manner.
- Although Infection control procedures followed published guidance we found shortfalls in the maintenance of the validation test recording system of the sterilisers and ultrasonic cleaning baths used in the decontamination process.
- Staff we spoke to understood the issues around safeguarding adults and children living in vulnerable circumstances.
- Although documentation was in place for the reporting of untoward incidents in the practice, a recent needle stick injury had not been managed appropriately and we could not find any records pertaining to the injury or how learning from such an injury was shared with the rest of the practice staff.
- Dentists provided dental care in accordance with current professional and National Institute for Care Excellence (NICE) guidelines.
- Patients could access treatment and urgent and emergency care when required.
- We saw records that showed staff received training appropriate to their roles in the practice.
- Recruitment records we saw did not contain written references prior to staff beginning with the company.
- Although staff we spoke with were committed to providing a quality service to their patients, staff did not feel supported by the various management structures within the company.
- Staff reported that there had been a rapid turnover of staff in the last twelve months including the recruitment of a temporary practice manager. We found that relationships between the temporary manager and staff were strained and this had contributed to the feeling by the staff we spoke with that the practice was not effectively managed.
- Due to the pressure of treating patients, dentists did not have sufficient time to complete clinical records in a contemporaneous manner. Clinical records tended to be completed by the clinicians at the end of the clinical day.
- We found that there were deficiencies in the operation of some clinical governance systems. This included shortfalls in the systems relating to whistleblowing and the monitoring of the expiry dates and condition of medicines used for dealing with medical emergencies in the practice.
We identified regulations that were not being met and the provider must:
- 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 appropriate systems are in place to meet health and safety regulations with respect to incident and accident reporting and the monitoring of water quality.
- Ensure that dental equipment is properly maintained and repaired in a timely manner.
- Ensure that whistleblowing concerns are appropriately managed.
- Ensure that dentists have sufficient time to enable them to carry out contemporaneous record keeping with respect to dental care records.
- Ensure the feedback from patients and staff is reviewed and improvements are implemented in response to poor feedback.
There were areas where the provider could make improvements and should:
- Consider providing the hygienist with the support of an appropriately trained member of the dental team.
- Review the availability of hearing loops for patients who are hard of hearing.
- Provide an annual statement in relation to infection prevention control required under The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.
- Consider the provision of an external name plate providing details of the dentists working at the practice including their General Dental Council (GDC) registration number in accordance with GDC guidance March 2012.
- Review the storage of products identified under Control of Substances Hazardous to Health ( COSHH) 2002 Regulations to ensure they are stored securely .
- Review the storage of dental materials and medicines requiring refrigeration to ensure they are stored in line with the manufacturer’s guidance and the fridge temperature is correctly monitored and recorded.
- Review the storage arrangements for local anaesthetic medicines.
- Review the frequency of audit of infection control procedures in line with current national guidelines HTM 01 05 (national guidance for infection prevention and control in dental practices).