dr. sean hasnain 300greatwesternstreet...dr. sean hasnain 300greatwesternstreet inspection report...

Overall summary

We carried out this unannounced inspection on 15February 2019 and a further announced inspection on the20 February 2019 (which was a continuation of theinspection process) under Section 60 of the Health andSocial Care Act 2008 in response to information ofconcern, and as part of our regulatory functions. Weplanned the inspection to check whether the registeredprovider was meeting the legal requirements in theHealth and Social Care Act 2008 and associatedregulations. The inspection was led by a CQC inspectorwho was supported by a specialist dental adviser and asecond CQC inspector.

To get to the heart of patients’ experiences of care andtreatment, we always ask the following five questions:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

These questions form the framework for the areas welook at during the inspection.

Our findings were:

Are services safe?

We found that this practice was not providing safe care inaccordance with the relevant regulations.

Are services effective?

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

Are services caring?

We found that this practice was providing caring servicesin accordance with the relevant regulations.

Are services responsive?

We found that this practice was providing responsive carein accordance with the relevant regulations.

Are services well-led?

We found that this practice was not providing well-ledcare in accordance with the relevant regulations.

Background

300 Great Western Street (known locally as RusholmeDental Practice) is in Rusholme, Manchester and providesNHS and private treatment to adults and children.

There is level access to the ground floor reception andsurgeries for people who use wheelchairs and those withpushchairs. On street parking is available near thepractice.

Dr. Sean Hasnain

300300 GrGreeatat WestWesternern StrStreeeettInspection Report

300 Great Western StreetRusholmeManchesterM14 4LPTel: 0161 2262548Website: www.rusholmedental.co.uk

Date of inspection visit: 15 February 2019Date of publication: 25/04/2019

1 300 Great Western Street Inspection Report 25/04/2019

The dental team includes three dentists including afoundation dentist, 13 dental nurses (eight of which aretrainees), a dental hygienist, two dental hygienetherapists (one of which is a foundation therapist), tworeceptionists and a practice manager. The practice hasfour treatment rooms.

The practice is owned by an individual who is theprincipal dentist there. They have legal responsibility formeeting the requirements in the Health and Social CareAct 2008 and associated regulations about how thepractice is run.

On the day of inspection, we collected one CQC commentcard filled in by a patient.

During the inspection we spoke with the dentistsincluding the foundation dentist, dental nurses, thedental hygiene therapist, the foundation hygienetherapist, a receptionist and the practice manager. Welooked at practice policies and procedures and otherrecords about how the service is managed.

The practice is open: Monday to Friday 9am to 1pm and2pm to 5pm.

Our key findings were:

• The premises were clean and well maintained, withthe exception of some areas which were dusty.Environmental cleaning could be improved.

• The provider had infection control procedures whichreflected published guidance with the exception of theprocesses for manually cleaning instruments.

• Staff did not all know how to deal with emergencies.Immediate action was needed to make appropriatemedicines and life-saving equipment available.

• The practice did not have effective systems to helpthem identify and manage risk to patients and staff.

• Improvements were needed to the safeguardingprocesses. The practice did not ensure that staff wereup to date with training. They knew theirresponsibilities to report any safeguarding concerns.

• The provider did not have thorough staff recruitmentprocedures.

• The clinical staff provided patients’ care and treatmentin line with current guidelines.

• Staff treated patients with dignity and respect andtook care to protect their privacy and personalinformation.

• Staff provided preventive care and supporting patientsto ensure better oral health.

• The appointment system took account of patients’needs.

• Staff felt involved and supported and worked well as ateam.

• The provider asked staff and patients for feedbackabout the services they provided.

• The systems to document and deal with complaintsrequired improvement.

• The provider did not have suitable informationgovernance arrangements.

We identified regulations the provider was notcomplying with. They must:

• Ensure care and treatment is provided in a safe way topatients.

• Ensure patients are protected from abuse andimproper treatment.

• Establish effective systems and processes to ensuregood governance in accordance with the fundamentalstandards of care.

• Ensure recruitment procedures are established andoperated effectively to ensure only fit and properpersons are employed.

• Act in accordance with the Duty of Candour.

Full details of the regulations the provider is notmeeting are at the end of this report.

There were areas where the provider could makeimprovements. They should:

• Review the availability of an interpreter service forpatients who do not speak English as their firstlanguage.

• Review staff awareness of the requirements of theMental Capacity Act 2005 and ensure all staff are awareof their responsibilities under the Act as it relates totheir role.

• Review the practice’s infection control procedures andprotocols taking into account the guidelines issued bythe Department of Health in the Health TechnicalMemorandum 01-05: Decontamination in primary caredental practices, and having regard to The Health andSocial Care Act 2008: ‘Code of Practice about theprevention and control of infections and related

Summary of findings


guidance’ (In particular, the arrangements fortransporting instruments, the illuminatedmagnification device and standards of environmentalcleaning).

Summary of findings


The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?We found that this practice was not providing safe care in accordance with therelevant regulations. We have told the provider to take action (see full details ofthis action in the Requirement Notices section at the end of this report).

The practice did not document, investigate or learn from incidents effectively.

Not all staff received training in safeguarding and insufficient information andsafeguarding resources were available. Staff knew how to recognise the signs ofabuse and how to report concerns.

Staff were qualified for their roles. The practice did not complete all the necessaryrecruitment checks or ensure the induction process was effective.

The premises were clean and well maintained, with the exception of some areaswhich were dusty. Environmental cleaning could be improved.

The practice followed national guidance for sterilising and storing dentalinstruments. Improvements could be made to the processes for transporting,manually cleaning and inspecting instruments.

The practice did not have suitable arrangements for dealing with medicalemergencies. Immediate action was necessary to address this. Not all staff werefamiliar with the emergency equipment provided.

Risks were not effectively assessed and acted on. For example, hazardoussubstances, staff immunity and health and safety.

Requirements notice

Are services effective?We found that this practice was providing effective care in accordance with therelevant regulations.

The dentists assessed patients’ needs and provided care and treatment in linewith recognised guidance. The dentists discussed treatment with patients so theycould give informed consent and recorded this in their records. We highlighted aminor improvement could be made to the information provided for dentalhygiene therapists to provide the appropriate treatment.

The practice had clear arrangements when patients needed to be referred toother dental or health care professionals.

The provider supported staff to complete training relevant to their roles and hadsystems to help them monitor this.

The staff were involved in quality improvement initiatives such as clinicalsupervision and regular clinical discussion as part of its approach in providinghigh quality care, this was evident during the inspection.

No action

Summary of findings


Are services caring?We found that this practice was providing caring services in accordance with therelevant regulations.

We received feedback about the practice from one person. They were positiveabout the services the practice provided. They told us their dentist listened tothem.

We saw that staff protected patients’ privacy and were aware of the importance ofconfidentiality. The use of CCTV had not been assessed in line with the GeneralData Protection Regulation (GDPR).

The practice was involved in a community project to clean the alleys, reducefly-tipping and rubbish, and restore pride and a sense of community.

No action

Are services responsive to people’s needs?We found that this practice was providing responsive care in accordance with therelevant regulations.

The practice’s appointment system took account of patients’ needs. Patientscould get an appointment quickly if in pain.

Staff considered patients’ different needs. This included providing facilities forpatients with a disability and families with children. The practice did not haveaccess to interpreter services.

The practice valued compliments from patients. The systems to document,investigate and respond to complaints required improvement.

No action

Are services well-led?We found that this practice was not providing well-led care in accordance with therelevant regulations. We have told the provider to take action (see full details ofthis action in the Requirement Notices and Enforcement Actions section at theend of this report).

There was a clear management structure and staff felt supported andappreciated.

The lack of effective governance had resulted in safety issues and incidentsoccurring. Systems were not in place to identify and manage risks.

The provider did not have thorough staff recruitment or induction procedures.

The practice team kept complete patient dental care records which were, clearlywritten or typed and stored securely. Staff records were not held securely.

The provider monitored clinical and non-clinical areas of their work to help themimprove and learn. This included asking for and listening to the views of patientsand staff.

Enforcement action

Summary of findings


Our findingsSafety systems and processes, including staffrecruitment, equipment and premises andradiography (X-rays)

The practice had some systems to keep patients safe.

The provision of training and information to reportconcerns about the safety of children, young people andvulnerable adults could be improved. The practice hadsome information about identifying, reporting and dealingwith suspected abuse, but this was generic and did notidentify who the safeguarding leads were. We asked forevidence of safeguarding training for staff. The provider wasunable to provide evidence of this for all staff. We sawcertificates of attendance at safeguarding training for eightmembers of staff. Information was not available that wouldsupport staff to recognise if patients were at risk of childsexual exploitation, modern-day slavery, trafficking orfemale genital mutilation.

Staff told us they would report any concerns they had tothe principal dentist or practice manager. Concerns. Wediscussed the requirement to notify the CQC of anysafeguarding referrals as staff were not aware. We alsohighlighted where staff training and access to the localsafeguarding team and resources would support staff atrisk of verbal abuse and aggression. Incidents such as thesewere not recorded or reported.

The practice had a whistleblowing policy, this was kept inthe office, we highlighted the need to make this readilyavailable to staff. Staff said they could raise concernswithout fear of recrimination.

The dentists used dental dams in line with guidance fromthe British Endodontic Society when providing root canaltreatment. In instances where the rubber dam was notused, such as for example refusal by the patient, and whereother methods were used to protect the airway, this wasdocumented in the dental care record and a riskassessment completed.

The business continuity plan was not up to date with thenecessary information which would be needed if eventsdisrupted the normal running of the practice.

The practice did not have appropriate recruitmentprocedures to help them employ suitable staff. We lookedat the staff recruitment records. Essential recruitment

checks were not consistently carried out before newemployees could commence work. For example, Disclosureand Barring Service (DBS) checks, obtaining references orevidence that individuals had the right to work in the UK. Ofthe members of staff listed as trainee dental nurses in thestaffing matrix, it was unclear whether some individualshad commenced employment or were on a trial basisshadowing staff as preliminary training contracts were notconsistently in place and there were no terms of thearrangements of their employment or work experience inthe staff files.

Records of up to date General Dental Council (GDC)registration and professional indemnity cover were notmaintained by the provider. Evidence was obtained fromstaff when we returned to the practice on 20 February.

The practice ensured that facilities and equipment weresafe and that equipment was maintained according tomanufacturers’ instructions, including electrical and gasappliances.

Records showed that fire detection equipment, such assmoke detectors and emergency lighting, were regularlytested and firefighting equipment, such as fireextinguishers, were regularly serviced. We highlightedwhere a rear fire exit was blocked by chairs and staff foundthe door difficult to open.

The practice had suitable arrangements to ensure thesafety of the X-ray equipment and had the requiredinformation in their radiation protection file.

We saw evidence that the dentists justified, graded andreported on the radiographs they took. The practice carriedout radiography audits every year following currentguidance and legislation.

The practice did not ensure that clinical staff were up todate with continuing professional development (CPD) inrespect of dental radiography.

Risks to patients

The systems to assess, monitor and manage risks to patientsafety were ineffective.

We asked to see the practice’s health and safety policiesand procedures, these were not available. The providershowed us a health and safety risk assessment template,which they completed in advance of our return visit to the

Are services safe?


practice. They had highlighted areas where action wasrequired to help manage potential risk. These includedfurther risk assessments of trainees, young workers, displayscreen equipment and the practice environment.

We noted the practice’s employer’s liability insurance hadexpired in July 2018. We were not assured that currentcover was in place until the insurer was contacted andprovided the necessary evidence.

We looked at the practice’s arrangements for safe dentalcare and treatment. The staff followed relevant safetyregulation when using needles and other sharp dentalitems. A sharps risk assessment had been undertaken andrecently reviewed and discussed with staff. Safe needlesystems were in use by some clinicians. Safer needleremoval and resheathing devices had been provided forclinicians who used traditional syringes.

The provider did not have an effective system in place toensure clinical staff had received appropriate vaccinations,including the vaccination to protect them against theHepatitis B virus, and that the effectiveness of thevaccination was checked. Of the clinical staff, evidence ofhepatitis B immunity was provided for 10 people. Therewere no results for eight members of staff.

A trainee dental nurse was in the process of receiving theirvaccinations. They did not have an individual riskassessment in place, despite carrying out decontaminationprocedures.

We were not assured that staff were familiar with theequipment to enable them to respond to a medicalemergency. Evidence of up to date training in emergencyresuscitation and basic life support was not available for 11members of staff. The practice induction included showingthe staff the location of the emergency kit, but this did notinclude ensuring staff were familiar with the correct use ofthe equipment provided. As a result, staff did not knowhow to operate the emergency medical oxygen and did notrecognise what the portable suction device was, or what itwas for.

Emergency equipment and medicines were not asdescribed in recognised guidance. Staff kept records ofweekly checks of these to make sure appropriatemedicines and equipment were available, within theirexpiry date, and in working order. The practice had notensured that the individuals responsible for checking thesewere appropriately trained to carry out this task. These

checks had failed to identify that needles and syringes werenot in place to administer emergency adrenaline in theevent of anaphylaxis (a severe allergic reaction). Immediateaction was taken to obtain these. Other items were missingfrom the emergency kit, these included oropharyngealairways, a child-sized self-inflating oxygen bag and childsized masks, and a range of adult and child-sized oxygenmasks. Glucagon was unrefrigerated and the expiry datehad not been changed in line with the manufacturer’sinstructions. This was brought to the attention of theprincipal dentist to review the arrangements against therequired standards as described in Resuscitation CouncilUK guidance. The General Dental Council requires dentalpractices to follow this.

A dental nurse worked with the dentists and the dentalhygienists and hygiene therapists when they treatedpatients in line with GDC Standards for the Dental Team.

The provider did not have suitable risk assessments tominimise the risk that can be caused from substances thatare hazardous to health. An incident had occurred in June2018 where the incorrect solution had been used in one ofthe dental unit waterlines.

The practice had a generic infection prevention and controlpolicy. This was not personalised to the practice. Theyfollowed guidance in The Health Technical Memorandum01-05: Decontamination in primary care dental practices(HTM 01-05) published by the Department of Health andSocial Care, with the exception of processes for manuallycleaning instruments. The practice had suitablearrangements for sterilising and storing instruments in linewith HTM 01-05. Improvements could be made byproviding clear procedures for the manual cleaning ofinstruments; including the correct temperature andconcentration of the solution to be used. Staff completedinfection prevention and control training and receivedupdates as required, and trainee dental nurses weresupported by qualified staff when working in thedecontamination room. We noted the illuminatedmagnification device, which is used to inspect instrumentsbefore sterilisation was broken, and staff did not transportinstruments from the dirty room to the clean room insealed waterproof containers.

The records to show equipment used by staff for cleaningand sterilising instruments was validated were not up todate and the practice could not assure us that these were

Are services safe?


carried out. This evidence was obtained from the memberof staff responsible and provided on the second day ofinspection. We saw evidence the equipment was servicedand used in line with the manufacturers’ guidance.

The practice had systems in place to ensure that any workwas disinfected prior to being sent to a dental laboratoryand before treatment was completed.

A Legionella risk assessment had been carried out inOctober 2018. We noted the report stated that evidence ofmonthly water temperature testing were not available atthis time. These records were still not available when werequested to see them. When we attended on the secondday, these had been obtained from the member of staffresponsible. These showed the practice had procedures toreduce the possibility of Legionella or other bacteriadeveloping in the water systems. All recommendations hadbeen actioned and records of water testing and dental unitwater line management were in place.

The practice could improve the general cleanliness of thepremises by providing cleaning schedules for staff tofollow, or to ensure they were familiar with the areas thatdifferent coloured mops and cloths should be used in. Themajority of the premises were visibly clean when weinspected, but some surfaces were dusty.

The provider had policies and procedures in place toensure clinical waste was segregated and storedappropriately in line with guidance.

The practice had not carried out any infection preventionand control audits since March 2017. There was noevidence that the findings of the last audit had beenreviewed. We spoke with the practice manager aboutcarrying out six-monthly audits in line with the guidance inHTM01-05.

Information to deliver safe care and treatment

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

We discussed with the dentist how information to deliversafe care and treatment was handled and recorded. Welooked at a sample of dental care records to confirm ourfindings and noted that individual records were written andmanaged in a way that kept patients safe. Dental carerecords we saw were complete, legible, were kept securelyand complied with General Data Protection Regulation(GDPR) requirements.

Patient referrals to other service providers containedspecific information which allowed appropriate and timelyreferrals in line with practice protocols and currentguidance. We discussed with the principal dentist howreferrals to the dental therapists could be improved byproviding patient specific instructions rather than relyingon standardised templates.

Safe and appropriate use of medicines

The provider did not have reliable systems for appropriateand safe handling of medicines.

The stock control system of medicines held on site had notidentified local anaesthetic in one of the dental surgerieswhich expired in November 2017. This was immediatelyremoved and brought to the attention of the principaldentist. The practice stored NHS prescriptions as describedin current guidance. The prescription logging processwould not identify if a prescription form was missing. Thiswas discussed with the practice manager to review theprocess.

The dentists were aware of current guidance with regardsto prescribing medicines.

Track record on safety and Lessons learned andimprovements

Arrangements to record, investigate and learn fromincidents and accidents were not effective. We discussedincidents that had not been recorded, and therefore actionhad not been taken to address these in a timely way. Forexample, incidents related to verbal abuse and aggression,a member of staff not returning their keys to the practiceafter leaving and the loss of personal information from stafffiles had not been reported, and action was not taken tosecure the premises until 19 February 2019.

The practice had systems for staff to report any incidents.We saw that accident reports from sharps injuries werepoorly recorded and no evidence could be shown thatthese were followed up appropriately.

The systems for reviewing and investigating when thingswent wrong required improvement. For example, theinvestigation after the incident in June 2018 did not includea thorough review of the hazardous substance involvedand a patient affected by this incident had not beenprovided with a full account of the event in line with the

Are services safe?


Duty of Candour. They had taken some actions to ensurethe wellbeing of the person involved but not providedthem with a full explanation of the circumstances, or anapology for the incident that had occurred.

There was no system for receiving and acting on safetyalerts, and the principal dentist and practice manager werenot aware of these until examples were shown to them. We

checked to ensure that medicines and equipment were notaffected by any relevant alerts. The practice manager gaveassurance that they would ensure that future alerts arereceived, acted upon and retained for reference. Thepractice learned from external safety events, such asnational publications, bulletins and alerts received fromthe NHS England area team.

Are services safe?


Our findingsEffective needs assessment, care and treatment

The practice had systems to keep dental practitioners up todate with current evidence-based practice. We saw thatclinicians assessed patients’ needs and delivered care andtreatment in line with current legislation, standards andguidance supported by clear clinical pathways andprotocols.

The staff were involved in quality improvement initiativesincluding regular clinical discussion as part of theirapproach in providing high quality care. They were also amember of a ‘good practice’ certification scheme. Theprincipal dentist provided mentorship and held regularclinical discussions with the foundation dentist and dentalhygiene therapist to support their development andprogression.

Helping patients to live healthier lives

The practice was providing preventive care and supportingpatients to ensure better oral health in line with theDelivering Better Oral Health toolkit.

The dentists prescribed high concentration fluoridetoothpaste if a patient’s risk of tooth decay indicated thiswould help them. They used fluoride varnish for childrenand adults based on an assessment of the risk of toothdecay.

The clinicians where applicable, discussed smoking,alcohol consumption and diet with patients duringappointments. The practice had a selection of healthpromotion leaflets to help patients with their oral health.

The practice was aware of national oral health campaignsand local schemes in supporting patients to live healthierlives. For example, local stop smoking services.

The dentists and dental hygiene therapists described to usthe procedures they used to improve the outcomes forpatients with gum disease. This involved providing patientspreventative advice, taking plaque and gum bleedingscores and recording detailed charts of the patient’s gumcondition.

Patients with more severe gum disease were recalled atmore frequent intervals for review and to reinforce homecare preventative advice.

The practice had recently been selected to take part in thegovernment’s Dental Prototype Agreement Scheme, to triala new NHS dental contract that aims to offer a new way ofproviding dental care, with an increased focus on diseaseprevention and the provision of interim care which can beprovided by dental hygiene therapists.

Consent to care and treatment

The practice obtained consent to care and treatment in linewith legislation and guidance.

The practice team understood the importance of obtainingand recording patients’ consent to treatment. The dentistsgave patients information about treatment options and therisks and benefits of these so they could make informeddecisions.

The practice’s consent policy included information aboutthe Mental Capacity Act 2005. The team understood theirresponsibilities under the act when treating adults whomay not be able to make informed decisions. We noted notall staff were familiar with the process to gain consentwhere patients lacked capacity. For example, where familymembers may have power of attorney or the patient didnot have any family. We highlighted the availability of localand national guidance in relation to this. The policy alsoreferred to Gillick competence, by which a child under theage of 16 years of age may give consent for themselves. Thestaff were aware of the need to consider this when treatingyoung people under 16 years of age.

Staff described how they involved patients’ relatives orcarers when appropriate and made sure they had enoughtime to explain treatment options clearly.

Monitoring care and treatment

The practice kept detailed dental care records containinginformation about the patients’ current dental needs, pasttreatment and medical histories. The dentists assessedpatients’ treatment needs in line with recognised guidance.

We saw the practice audited patients’ dental care recordsto check that the clinicians recorded the necessaryinformation. We highlighted where the dentists coulddocument instructions to the dental hygiene therapistsmore clearly in the dental care records.

Effective staffing

The systems to ensure staff had the skills, knowledge andexperience to carry out their roles could be improved. For

Are services effective?(for example, treatment is effective)


example, the induction checklist did not documentarrangements to ensure staff were familiar with correctsafeguarding processes or medical emergencyarrangements. The induction process had not beencompleted fully for all new members of staff.

Co-ordinating care and treatment

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

The dentists confirmed they referred patients to a range ofspecialists in primary and secondary care if they neededtreatment the practice did not provide.

The practice had systems to identify, manage, follow upand where required refer patients for specialist care whenpresenting with dental infections.

The practice also had systems for referring patients withsuspected oral cancer under the national two week waitarrangements. This was initiated by NICE in 2005 to helpmake sure patients were seen quickly by a specialist.

The practice monitored all referrals to make sure they weredealt with promptly.

Are services effective?(for example, treatment is effective)


Our findingsKindness, respect and compassion

Staff treated patients with kindness, respect andcompassion.

Staff were aware of their responsibility to respect people’sdiversity and human rights.

We saw that staff treated patients respectfully,appropriately and kindly and were friendly towardspatients at the reception desk and over the telephone.

Practice information and magazines were provided in thewaiting room for patients to read.

The practice was involved in a community project to cleanthe alleys, reduce fly-tipping and rubbish, increaserecycling, and improve the environment for residents andbusinesses to restore pride in the area.

Privacy and dignity

The practice respected and promoted patients’ privacy anddignity.

Staff were aware of the importance of privacy andconfidentiality. The layout of reception and waiting areasprovided limited privacy when reception staff were dealingwith patients. If a patient asked for more privacy, staff couldtake them into another room. The reception computerscreens were not visible to patients and staff did not leavepatients’ personal information where other patients mightsee it.

Staff password protected patients’ electronic care recordsand backed these up to secure storage. They stored paperrecords securely. The provider had installed a closed-circuittelevision system, (CCTV), externally and internally in thecorridor, reception and the waiting areas. The provider hadnot displayed information informing patients for whatpurpose the CCTV was in use and to make them aware oftheir right of access to footage which contains their images.

A privacy impact assessment had not been carried out toensure the CCTV was proportionate and the images storedand accessed appropriately. This was raised with thepractice manager to address.

Involving people in decisions about care andtreatment

Staff helped patients to be involved in decisions about theircare and were aware of the

requirements under the Equality Act. They were notfamiliar with the Accessible Information Standard. This is arequirement to make sure that patients and their carerscan access and understand the information they are given.

Staff did not have access to interpreter services for patientswho did not understand or speak English. Patients weretold about multi-lingual staff that might be able to supportthem or brought family members who could speak Englishto help them understand any care proposed or provided.

Staff communicated with patients in a way that they couldunderstand and communication aids and easy readmaterials were available.

The practice gave patients clear information to help themmake informed choices about their treatment. Patientsconfirmed that staff listened to them, did not rush themand discussed options for treatment with them. A dentistdescribed the conversations they had with patients tosatisfy themselves they understood their treatmentoptions.

The practice’s website and information leaflet providedpatients with information about the range of treatmentsavailable at the practice.

The dentists described to us the methods they used to helppatients understand treatment options discussed. Theseincluded for example, photographs, models and X-rayimages shown to the patient/relative to help them betterunderstand the diagnosis and treatment.

Are services caring?


Our findingsResponding to and meeting people’s needs

The practice organised and delivered services to meetpatients’ needs. It took account of patient needs andpreferences.

Staff were clear on the importance of emotional supportneeded by patients when delivering care.

Staff told us that they currently had some patients forwhom they needed to make adjustments to enable themto receive treatment. For example, patient dental carerecords were flagged if they were unable to access thefirst-floor surgery. The practice had made some reasonableadjustments for patients with disabilities in line with adisability access audit. These included step-free access forwheelchair users through a side entrance and an accessibletoilet. We highlighted that grab rails and a call bell couldalso be installed in the patient toilets.

The practice provided a private prayer room which wasavailable to staff and patients.

Patients could choose to receive appointment cards andpostal reminders for forthcoming appointments. Stafftelephoned some patients on the morning of theirappointment to make sure they could get to the practice.Staff said that many patients dropped into the practice toarrange appointments.

Timely access to services

Patients could access care and treatment from the practicewithin an acceptable timescale for their needs.

The practice displayed its opening hours in the premises,and included it in their information leaflet and on theirwebsite.

The practice had an appointment system to respond topatients’ needs. Patients who requested urgent advice orcare were offered an appointment the same day.Appointments ran smoothly on the day of the inspectionand patients were not kept waiting.

The practice’s website, information leaflet andanswerphone provided telephone numbers for patientsneeding emergency dental treatment during the workingday and when the practice was not open. In addition, thepractice was part of a local scheme to provide urgentdental care to one patient per working day who did nothave a dentist. These patients were scheduled by a centralbooking office who were responsible for providing thenecessary information to the practice.

Listening and learning from concerns and complaints

The systems to document complaints and concerns shouldbe reviewed to ensure they are investigated and respondedto appropriately to improve the quality of care.

The practice had a policy providing guidance to staff onhow to handle a complaint. The practice information leafletexplained how to make a complaint.

The practice manager was responsible for dealing withthese. Staff would tell the practice manager about anyformal or informal comments or concerns straight away sopatients received a quick response.

The practice manager aimed to settle complaints in-houseand invited patients to speak with them in person todiscuss these. Where complaints were dealt with andresolved verbally, these were not documented. Informationwas available about organisations patients could contact ifnot satisfied with the way the practice dealt with theirconcerns.

We asked to see how comments, compliments andcomplaints the practice received were handled. The mostrecently documented complaint investigation that couldbe found was from September 2017. This was a response toa patient, there was no information about which patientthis response was to or whether it had been sent to them.

We highlighted the importance of documenting andresponding to concerns appropriately to improve theservice.

Are services responsive to people’s needs?(for example, to feedback?)


Our findingsLeadership capacity and capability

We found the principal dentist needed to prioritise theleadership of the practice, and ensure that staff in leadroles are provided with the experience, capacity and skillsto deliver the practice strategy and address risks to it.

Staff were lacking in knowledge about issues and prioritiesrelating to the governance and quality of services. Duringthe inspection, they recognised there were deficiencies,understood the challenges and demonstrated acommitment to address them.

Staff changes had affected capacity to ensure thatleadership and governance systems were up to date andfunctioning effectively. The principal dentist had prioritisedthe delivery of the new prototype NHS contract, providingclinical support to staff, and ensuring patients could accessdental care during this time.

Vision and strategy

Staff were familiar with the challenges of providing servicesto meet the high needs of the local population. They wereaware of the local demographics of the population, whichincludes a large student population, and high levels ofsocial and economic deprivation. They were involved in aproject to clean up the local area and strengthencommunity relationships.

Culture

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

Staff stated they felt respected and supported. The practicefocused on the needs of patients and ensuring they couldaccess care. They were keen to develop the skill mix ofclinical staff to facilitate this.

Openness, honesty and transparency were notdemonstrated when responding to incidents andcomplaints. The provider did not have systems to ensurecompliance with the requirements of the Duty of Candour.There was no evidence that they had acted fully in line withthe Duty of Candour when a recent incident had occurred.They had taken some actions to ensure the wellbeing ofthe person involved but not provided them with a fullexplanation of the circumstances, or an apology for theincident that had occurred.

Governance and management

The principal dentist had overall responsibility for themanagement and clinical leadership of the practice. Thepractice manager was responsible for the day to dayrunning of the service.

The system of clinical governance was inadequate tosupport the delivery of services and incidents had occurredas a result of this. Many policies, protocols and procedureswere generic, not appropriate to the systems in the practiceor missing. There was no evidence that these werereviewed on a regular basis, except for sharps safety whichhad been reviewed and discussed with staff in January2019.

There were ineffective processes for identifying andmanaging risks, issues and performance. Opportunitieswere missed to identify these areas when completing theannual self-assessment document which is required fordental practices who provide foundation training.

For example:

• The provider had failed to ensure appropriate medicalemergency arrangements were in place.

• A lack of systems to receive, or knowledge of patientsafety alerts.

• Evidence could not be provided to show thatappropriate action had not been taken to follow up aftersharps injuries.

• Safeguarding arrangements were ineffective.• Incidents were poorly documented, not investigated

inadequately and the Duty of Candour had not beenfollowed.

• Staff recruitment and induction processes wereineffective.

• Hazardous substances were not appropriately assessedand expired medicines were identified.

• Complaints were not documented, investigated orresponded to appropriately.

• The practice were not assured that public liabilityinsurance and individual medical indemnities were upto date until evidence of these was requested.

• The practice did not ensure that staff were up to datewith training, including safeguarding, medicalemergencies and basic life support.

• The provider could not be assured that staff carrying outkey roles, did so appropriately. For example, Legionellachecks and the validation of sterilisation equipment. We



saw records showing that medical emergencyequipment checks were carried out by a person whohad only done a short period of shadowing and workexperience at the practice.

Appropriate and accurate information

The processes to ensure the security of, and act onappropriate and accurate information were not effective.

The practice had information governance arrangementsand staff were aware of the importance of these inprotecting patients’ personal information. The practicemanager told us they had identified that staff’s personalinformation had gone missing. Due to the disorganisationof staff files, it was difficult to identify exactly what wasmissing from the files which, at the time, had beenunlocked and accessible to all staff. The CCTVarrangements had not been reviewed in line with GDPRrequirements.

Engagement with patients, the public, staff andexternal partners

The practice involved patients, the public, staff andexternal partners to support high-quality sustainableservices.

The practice used verbal comments to obtain patients’views about the service.

Patients were encouraged to complete the NHS Friendsand Family Test (FFT). This is a national programme toallow patients to provide feedback on NHS services theyhave used. Of the most recent 20 responders, 55% wouldrecommend the service to a friend or family member.

The practice gathered feedback from staff throughmeetings and informal discussions. New members of stafftold us that they spent time shadowing and learning frommore experienced members of the team. Staff knew toreport any issues or concerns they had to the principaldentist or practice manager.

Continuous improvement and innovation

There were some systems and processes for learning,continuous improvement and innovation.

The practice had quality assurance processes to encouragelearning and continuous improvement. These included theprovision of clinical supervision, weekly tutorials providedby the principal dentist and reviewing the quality of dentalcare records and radiographs. We highlighted where theinformation provided to the dental hygiene therapistscould be improved. There had been no audits of infectionprevention and control since March 2017. We spoke withthe practice manager about carrying out six-monthly auditsin line with the guidance in HTM 01-05.

The principal dentist showed a commitment to learningand improvement and valued the contributions made tothe team by individual members of staff. Staff werecomplimentary about the support they received.

There were plans to ensure staff had annual appraisals.Recent staff changes had impacted on this. They discussedlearning needs, general wellbeing and aims for futureprofessional development informally and at staff meetings.

The provider did not ask staff for evidence that theycompleted ‘highly recommended’ training as per GeneralDental Council professional standards. This includesundertaking medical emergencies and basic life supporttraining annually, and appropriate radiation protection andsafeguarding training updates. We gave the practice theopportunity to request staff for evidence of training whenwe returned to complete the inspection on the second day.Four members of staff provided evidence of safeguardingtraining and one brought evidence of medical emergencytraining. There were still gaps where staff could not becontacted to provide this.



Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activityDiagnostic and screening procedures

Surgical procedures

Treatment of disease, disorder or injury

Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

The registered person had not done all that wasreasonably practicable to mitigate risks to the health andsafety of service users receiving care and treatment. Inparticular:

Medical emergency arrangements were ineffective. Thearrangements were not in line with GDC standards andResuscitation Council UK guidance.

• During the routine check of the medical emergency kitit was identified that there were no needles or syringesto be able to deliver emergency adrenaline in the eventof anaphylaxis. Glucagon was stored unrefrigerated inthe kit and the expiry date had not been changed in linewith the manufacturer’s instructions.

• There was no paediatric self-inflating bag/mask, therequired range of oropharyngeal airways were notavailable and two were unpouched.

• The required range of oxygen masks were not available.• Expired oxygen masks were kept alongside new masks.• Staff did not know how to operate the emergency

medical oxygen and did not recognise what theportable suction device was, or what it was for. Theinduction only included the location of the kit, and notfamiliarising staff with it.

Arrangements for medicine control requiredimprovement.

• Local anaesthetic cartridges which expired inNovember 2017 were found in the downstairs surgerydrawer ready for use. We were told this surgery was inregular use.

• The prescription logging system would not identify if aprescription was missing.

• There was a lack of awareness of the yellow cardreporting system or sepsis.

Regulation

This section is primarily information for the provider

Requirement notices


The processes for incident reporting and investigationwere ineffective.

• A review of the incidents showed that these were poorlyrecorded. For example, some incidents in the accidentbook were not acted on and there was no evidencethese were investigated and followed up appropriately,particularly after staff received sharps injuries.

• We were informed of incidents that had occurred butnot been recorded and acted on.

• There was a lack of hazardous substance control. Anincident involving a hazardous substance had occurredon 27 June 2018. There was no COSHH assessmentcarried out on this solution before it was put into usedespite staff stating the labelling of the product was notclear. The COSHH risk assessment for the new solutionnow being used was incomplete as it only stated therisks and action to be taken after splashes to eyes oringestion. It did not include how the product is to bestored or used safely and the product safety data sheetwas not available.

Regulation 12(1)


Surgical procedures


Regulation 13 HSCA (RA) Regulations 2014 Safeguardingservice users from abuse and improper treatment

The registered person did not have systems andprocesses in place that operated effectively to preventabuse of service users. In particular:

• The safeguarding policy was generic and did notidentify lead roles, or specify local arrangements forsafeguarding.

• The practice did not ensure that staff completedsafeguarding training to the appropriate level orupdated their training at appropriate intervals.Evidence of training was only seen for seven membersof staff. There was no evidence that the inductionincluded ensuring staff were familiarised withsafeguarding arrangements.

• The registered person did not access safeguardingadvice or resources, or work in partnership with otherrelevant bodies to enable staff to highlight patients

Regulation


Requirement notices


living in vulnerable circumstances. For example, wherechildren were not brought to appointments, clinicaladvice was not followed, or family circumstances suchas drug use was suspected.

• Information about current procedures and guidanceabout raising concerns about abuse was not accessibleto staff. For example, there was no information relatingto areas of safeguarding highly relevant to thepopulation and area, including Female GenitalMutilation, domestic violence, trafficking and modernslavery.

Regulation 13(1)(2)


Surgical procedures


Regulation 20 HSCA (RA) Regulations 2014 Duty of candour

The registered person had failed to act in an open andtransparent way with relevant persons in relation to careand treatment provided to service users in carrying on aregulated activity. In particular:

• An incident had occurred on 27 June 2018. There wasno evidence that the registered person had ensuredthat a full investigation was carried out or takenappropriate action to provide the patient affected witha full explanation of, and apology for the incident thatoccurred on the above date.

Regulation 20(1)

Regulation


Requirement notices


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.


Surgical procedures


Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

The registered person had systems or processes inplace that operated ineffectively in that they failed toenable the registered person to assess, monitor andimprove the quality and safety of the services beingprovided. In particular:

The registered person had not established effectivesystems and processes to ensure good governance inaccordance with the fundamental standards of care.

• Many policies were generic, undated or out of date, notpersonalised to the practice, and lead roles were notidentified. Several policies (IPC, recruitment, health andsafety, RIDDOR and incident reporting) could not befound.

• Opportunities had been missed to review thegovernance and safety systems during the annualself-assessment process that was required by thedental foundation training programme.

• There was no system to receive patient safety alerts andthe registered person was not aware of these.

The registered person had systems or processes inplace that operated ineffectively in that they failed toenable the registered person to assess, monitor andmitigate the risks relating to the health, safety andwelfare of service users and others who may be at risk.

• The registered person had not ensured that appropriateequipment and training was provided to respond tomedical emergencies. The systems for checking theavailability of medical emergency kit had failed toidentify missing or expired items.

• Health and safety risks had not been assessed in thepremises. We noted on both days that the signed firedoor at the rear of the practice was partially blocked bya chair and staff struggled to undo the bolts on thisdoor.

Regulation


Enforcement actions


• There was a lack of effective system for risk assessinghazardous substances. The registered person had notensured a thorough review of hazardous substancesused in the practice after the incident.

• Incidents, including sharps injuries were poorlydocumented. There was a lack of effective investigationand following up of individuals after sharps incidents.We were told of incidents that had occurred, but hadnot been recorded or acted on in a timely way.

• Staff had not identified and removed expiredmedicines. Systems were not effective to ensure thesecurity of NHS prescriptions.

• Systems were not in place to ensure that public liabilityinsurance was up to date until the company wascontacted and evidence of a current policy provided.

There was additional evidence of poor governance. Inparticular:

• Infection prevention and control audits (which arerequired on a six-monthly basis) had not been carriedout since March 2017.

• Evidence and information was not available to provideassurance that key tasks were carried out effectivelyuntil individual staff members could be spoken to. Forexample, Legionella and protein residue testing, andthe individuals tasked with carrying out medicalemergency equipment checks were appropriate to doso.

• There was no privacy impact assessment or informationgovernance processes in place for the CCTV in thereception, waiting rooms and external to the front andrear of the property.

• Verbal complaints were not documented and there wasno evidence that formal complaints were documented,investigated and responded to appropriately and in atimely way.

• The lack of evidence that staff are up to date withtraining- evidence of up to date life support, infectionprevention and control and radiographic update(IR(ME)R) training was not requested from staff.

• The practice had failed to ensure that staffs’ personalinformation was held securely. During the inspection, aloss of personal information from staff files was broughtto light.

Regulation 17(1)


Enforcement actions



Surgical procedures


Regulation 19 HSCA (RA) Regulations 2014 Fit and properpersons employed

The registered person had not ensured that all theinformation specified in Schedule 3 of the Health andSocial Care Act 2008 (Regulated Activities) Regulations2014 was available for each person employed. Inparticular:

• Staff files were incomplete, the practice manager wasunable to find some of the evidence requested. Forexample, DBS checks, evidence of identification,indemnity and immunity. Due to the poor organisationof staff files, the practice was unable to correctlyidentify the information that was missing.

• DBS (or risk assessments) were not carried out on allnew members of staff. Nine new members of staff didnot have a DBS carried out at the point of employment.

• There was no evidence that a right to work check hadbeen carried out on one member of staff. They did notknow if the college that the individual had enrolled withhad carried out any checks.

• Current references were not consistently sought for newmembers of staff.

• The provision of preliminary training contracts wasinconsistent, some new members of staff were notprovided with a contract. It was unclear whether somemembers of staff who were listed as trainee dentalnurses in the staffing matrix had commencedemployment as there were no terms of thearrangements of their employment or work experiencein the staff files.

• Evidence of appropriate immunity to Hepatitis B wasnot available for seven members of clinical staff. Fivestaff members had received the vaccinations but hadnot been asked to provide evidence that these hadprovided adequate protection; One trainee dentalnurse had evidence of two vaccinations in November2017 only, and there was no evidence that a dentist hadreceived the vaccinations.

• The induction process was inconsistent and insufficientto ensure new members of staff were prepared to work

Regulation


Enforcement actions


safely in the practice. For example, it did not includesafeguarding or familiarity with emergency equipment.A dental nurse who commenced work in July 2018 hada blank induction checklist in their file.

Regulation 19(3)


Enforcement actions


dr. sean hasnain 300greatwesternstreet...dr. sean hasnain 300greatwesternstreet inspection report...

Documents