Rocky Lane Dental Practice

We carried out an announced comprehensive inspection at Rocky Lane Dental Practice on 8 March 2016 and at this time breaches of a legal requirement were found. After the comprehensive inspection the practice wrote to us and told us that they would take action to meet the following legal requirement set out in the Health and Social Care Act (HSCA) 2008:

Regulation 17 HSCA (RA) Regulations 2014 Good governance

On 17 January 2017 we carried out a follow up review of this service under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was carried out to check whether the provider had completed the improvements needed and identified during the comprehensive inspection in March 2016.

We reviewed the practice against one of the five questions we ask about services: is the service well-led? This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Rocky Lane Dental Practice on our website at www.cqc.org.uk

We reviewed information Rocky Lane Dental Practice had sent us as part of this review, checked whether they had followed their action plan and to confirm that they now met the legal requirements.

Our findings were:

Are services well-led?

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

Background

The practice is situated in Heswall town centre. It has one dentist, two dental hygienists, two qualified dental nurses, an apprentice and a receptionist. The practice provides primary dental services to predominately private patients and some NHS patients. The practice is open as follows:

Monday 8am – 4pm

Tuesday 9am – 5.30pm

Wednesday 9am – 3pm

Thursday 10am – 7pm

Friday 8.30am – 4pm

The principal dentist is registered with the Care Quality Commission (CQC) as an individual and is legally responsible for making sure that the practice meets the requirements relating to safety and quality of care, as specified in the regulations associated with the Health and Social Care Act 2008.

Our key findings were:

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

• A recruitment policy had been implemented that included obtaining the required information for people working at the practice such as photographic identification, references, qualifications and Disclosure and Barring Service (DBS) checks. We were told that new staff had undertaken the required checks and the information was now held on file.

Governance arrangements included:

• An audit programme had been implemented and included audits, such as decontamination, radiographs and record keeping.

• Risks such as health and safety, fire and Legionella had been assessed and action taken to mitigate the risks.
• A patient satisfaction survey had been undertaken and the feedback was all positive.

The complaints procedure was displayed in the waiting room.

We found that the practice had acted upon other recommendations made at the previous inspection to improve the service and care.

We carried out an announced comprehensive inspection on 8 March 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 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

The practice is situated in Heswall town centre. The practice has one dentist, two dental hygienists, three qualified dental nurses and a receptionist. The practice provides primary dental services to predominately private patients and some NHS patients. The practice is open as follows:

Monday 8am – 4pm

Tuesday 9am – 5.30pm

Wednesday 9am – 3pm

Thursday 10am – 7pm

Friday 8.30am – 4pm

The principal dentist is the registered provider. A registered provider is registered with the Care Quality Commission to manage the service. 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.

We received feedback from 47 patients about the service. The 44 CQC comment cards seen and three patients spoken to reflected very positive comments about the staff and the services provided. Patients commented that the practice appeared clean and tidy and they found the staff very caring, friendly and professional. They had trust and confidence in the dental treatments and said explanations from staff were clear and understandable.

Our key findings were:

• The practice recorded accidents and complaints and cascaded learning to staff when they occurred.
• Staff had received safeguarding training and knew the processes to follow to raise any concerns. However some staff’s training was out of date.
• There were sufficient numbers of suitably qualified staff to meet the needs of patients.
• Staff had been trained to deal with medical emergencies and emergency medicines and emergency equipment were available.
• Infection prevention and control procedures were in place.
• Patients’ care and treatment was planned and delivered in line with evidence based guidelines, best practice and current legislation.
• Patients received clear explanations about their proposed treatment, costs, benefits and risks and were involved in making decisions about it.
• Patients were treated with dignity and respect and their confidentiality was maintained.
• The appointment system met the needs of patients and waiting times were kept to a minimum.
• The practice staff felt valued, involved and worked as a team.
• There was a lack of a robust governance framework with a lack of audits, systems for patients to feedback, quality monitoring and written information for patients in relation to services provided and how to make complaints.

We identified a regulation that was not being met and the provider must:

• Ensure a practice recruitment policy and related procedures are implemented and the recruitment arrangements are in line with Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
• Ensure audits of various aspects of the service, such as radiography, infection control and dental care records are undertaken at regular intervals to help improve the quality of the service. The practice should also ensure all audits have documented learning points that are shared with all relevant staff and the resulting improvements can be demonstrated as part of the audit process.
• Ensure a system is implemented by which patient views are encouraged, obtained, analysed and used to help improve services.
• Ensure that the complaints process is publicised and patients are informed and supported to make complaints when appropriate.
• Ensure that audit and governance systems remain effective by implementing a full range of appropriate policies and procedures for the service and review and monitor their effectiveness on a regular basis.
• Ensure risk assessments are reviewed and updated to reflect current regulations and guidance and are continually monitored, including health and safety, fire risk assessments and Legionella risk assessment.

There were areas where the provider could make improvements and should:

• Review the practice’s system for the recording, investigating and reviewing of clinical incidents and significant events with a view to preventing further occurrences and, ensuring that improvements are made as a result.
• Review the format of staff meetings to include documented dissemination of lessons learnt from significant incidents, events and complaints and sharing improvements from audits and patient feedback.
• Review the practice’s policies and procedures for safeguarding to include the identification of a safeguarding lead and that training at an appropriate level is undertaken on a regular basis by all staff.
• Review the practice’s arrangements for receiving and responding to patient safety alerts, recalls and rapid response reports issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and through the Central Alerting System (CAS), as well as from other relevant bodies such as, Public Health England (PHE).
• Review displaying of local rules where X-ray equipment is used.
• Review the implementation of a business continuity plan in order to minimise the risks and be able to respond to and manage major incidents and emergency situations.
• Review the implementation of a practice information leaflet to inform patients of the services offered, opening times, costs, staffing and the complaints procedure. Publicise information for patients on how to access emergency dental care and treatment outside of normal practice working hours.