Douglas Lee Dental Practice

We carried out a follow-up inspection at Douglas Lee Dental Practice on 6 November 2017.

We had undertaken an announced comprehensive inspection of this service on 3 March 2017 as part of our regulatory functions where a breach of legal requirements was found.

After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach. This report only covers our findings in relation to those requirements. We checked whether they had followed their action plan to confirm that they now met the legal requirements.

We reviewed the practice against one of the five questions we ask about services: are the services well led? You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Douglas Lee Dental Practice on our website at www.cqc.org.uk.

We revisited Douglas Lee Dental Practice as part of this review and checked whether they now met the legal requirements. We carried out this announced inspection on 6 November 2017 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.

• Is it well-led?

This question forms the framework for the areas we look at during the inspection.

Our findings were:

Are services well-led?

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

Background

Douglas Lee Dental practice is located in Accrington, Lancashire and provides private routine and preventative dental care.

A practice manager, two dentists, two dental hygienists, a dental technician and two dental nurses work at the practice. The practice provides access and facilities for wheelchair users.

The practice is owned by a company 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  was the principal dentist.

The practice is open:

Monday to Friday from 9:00am to 6:00pm

Saturday from 9:00am to 12:30pm

Our key findings were:

• There was a recruitment policy and procedure in place and robust checks completed on staff.
• An infection prevention and control audit had been carried out.

The practice had also acted upon other recommendations:

• X-rays quality audits were now in place and conducted in line with guidance.
• Significant events were now reviewed and in place.
• Rubber dams had been purchased in line with current guidance.

We carried out an announced comprehensive inspection on 3 March 2017 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

Douglas Lee Dental practice is located in Accrington, Lancashire and provides whole population private routine and preventative dental care. A practice manager, two dentists, two dental hygienists, a dental technician and two dental nurses work at the practice. The practice provides access and facilities for wheelchair users.

The practice is open Monday and Tuesday 09:00 – 17:30, Wednesday and Thursday 09:00 – 19:30 and Friday 09:00 – 13:00.

The practice owner is the registered manager. A registered manager is a person who is registered with the Care Quality Commission (CQC) 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 reviewed 22 CQC patient feedback comment cards on the day of our visit. Patients spoke highly of the staff and the standard of care provided by the practice. Patients commented that they felt involved in all aspects of their care and found the staff to be helpful, respectful, and friendly, and said they were treated in a clean and tidy environment.

Our key findings were:

• The practice was well organised, visibly clean and free from clutter.
• An infection prevention and control policy was in place.
• The practice had a safeguarding policy and staff were aware on how to escalate safeguarding issues for children and adults should the need arise.
• Staff received annual medical emergency training. Equipment for dealing with medical emergencies reflected guidance from the resuscitation council (UK).
• Dental professionals provided treatment in accordance with current professional guidelines.
• A process was established to seek patient feedback about the service.
• Patients could access urgent care when required.
• Dental professionals were maintaining their continued professional development in accordance with their professional registration.
• A process was in place for managing complaints.
• The practice was actively involved in promoting oral health.
• The practice had systems for recording incidents, accidents and near misses. A near miss that occurred last year had not been recorded.
• A recruitment policy was not in place and recruitment checks were not robust.
• A programme of audit was not in place for 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 effective systems are developed to monitor and improve the quality and safety of the service, such as the undertaking of regular audits of various aspects of the service. The practice should also ensure all audits have documented learning points and the resulting improvements can be demonstrated.

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

• Review the practice’s system for the recording and reviewing incidents or significant events to ensure that all incidents are recorded, including near misses.
• Review the practice’s protocols for the use of rubber dam for root canal treatment giving due regard to guidelines issued by the British Endodontic Society.
• Review the process for monitoring equipment requiring decontamination, in particular the dental treatment chairs, taking into account the guidelines issued by the Department of Health - Health Technical Memorandum 01-05.
• Review the practice’s protocols for recording in the patient dental care records or elsewhere the reason for taking the X-ray and quality of the X-ray giving due regard to the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2000.