We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

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1 Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Stephenson House 75 Hampstead Road, London, NW1 2PL Tel: Date of Inspection: 05 September 2014 Date of Publication: October 2014 We inspected the following standards as part of a routine inspection. This is what we found: Consent to care and treatment Care and welfare of people who use services Cooperating with other providers Safeguarding people who use services from abuse Assessing and monitoring the quality of service provision Inspection Report Stephenson House October

2 Details about this location Registered Provider Overview of the service Type of services Regulated activities Central and North West London NHS Foundation Trust Brookside Dental Clinic is part of Buckinghamshire Priority Dental Service a community dental service which is provided by Central and North West London NHS Foundation Trust. They provide dental treatment for patients who, due to their complex needs, are unable to access dental care and treatment through general dental services. Ambulance service Community healthcare service Dental service Community based services for people with a learning disability Community based services for people with mental health needs Prison Healthcare Services Rehabilitation services Community based services for people who misuse substances Diagnostic and screening procedures Family planning Nursing care Surgical procedures Transport services, triage and medical advice provided remotely Treatment of disease, disorder or injury Inspection Report Stephenson House October

3 Contents When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'. Summary of this inspection: Page Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 More information about the provider 5 Our judgements for each standard inspected: Consent to care and treatment 6 Care and welfare of people who use services 8 Cooperating with other providers 10 Safeguarding people who use services from abuse 12 Assessing and monitoring the quality of service provision 13 About CQC Inspections 15 How we define our judgements 16 Glossary of terms we use in this report 18 Contact us 20 Inspection Report Stephenson House October

4 Summary of this inspection Why we carried out this inspection This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection. This was an announced inspection. How we carried out this inspection We looked at the personal care or treatment records of people who use the service, carried out a visit on 5 September 2014, checked how people were cared for at each stage of their treatment and care and talked with people who use the service. We talked with staff and were accompanied by a specialist advisor. What people told us and what we found This was a scheduled inspection of Brookside Dental Clinic which is a part of Buckinghamshire Priority Dental Service (BPDS) a service provided by Central and North West London NHS Foundation Trust. Brookside Dental Clinic also provides out of hours emergency dental care from the same premises. We did not inspect the out of hours service. Patients were referred to the BPDS when their treatment needs could not be met by general dental services. For example; patients with learning disabilities, complex medical problems or severe mental health problems and children with severe behavioural management problems. We saw records were kept to ensure the service could track a patient's progress from referral through to treatment or referral for general anaesthetic and discharge. Appropriate care planning took place and was co-ordinated to provide a seamless service for patients. There were robust systems in place to ensure that proper, valid, informed consent was obtained before dental treatment was undertaken. Staff knew how and when to contact an Independent Mental Capacity Advocate (IMCA). An IMCA's role is to help particularly vulnerable people who lack the ability to make important decisions about medical treatment. The service carried out intra-venous sedation and inhalation sedation for patients who were very nervous of dental treatment. Inhalation sedation is a form of sedation, a mixture of nitrous oxide and oxygen breathed through a nosepiece. Intra-venous sedation is a technique whereby a sedating drug is given to a patient by injection. We found that Intravenous sedation was delivered according to the standards set out by Royal College of Anaesthetists and the Department of Health Standing Committee Guidelines in Conscious Sedation of The service sought feedback from their patients in the form of a satisfaction survey. The Inspection Report Stephenson House October

5 results for Brookside Dental Clinic had formed part of the overall analysis of patient satisfaction for Buckinghamshire Priority Dental Service (BPDS), There was evidence of a number of audits of the BPDS. These were in addition to those audits identified as mandatory by the Central and North West London NHS Foundation Trust, which were fed into the Trust's clinical governance framework. This meant that the service monitored the quality of their patient care both as an individual clinic and as part of the wider organisation. You can see our judgements on the front page of this report. More information about the provider Please see our website for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions. There is a glossary at the back of this report which has definitions for words and phrases we use in the report. Inspection Report Stephenson House October

6 Our judgements for each standard inspected Consent to care and treatment Before people are given any examination, care, treatment or support, they should be asked if they agree to it Our judgement The provider was meeting this standard. Where patients did not have the capacity to consent, the provider acted in accordance with legal requirements. Reasons for our judgement Before patients received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. Staff explained how treatment options were discussed with their patients. We reviewed a sample of clinical records and found that particular attention was paid to ensuring informed consent was obtained before treatment was carried out. Patients were involved in all the discussions about treatment options and the risks and benefits of the proposed treatment. This meant that patients had information about the alternative options for their care and treatment and the risks and benefits of each. There were robust systems in place to ensure that proper, valid, informed consent was obtained before dental treatment was undertaken. The Clinical Director of the service explained how consent was obtained. The service used the appropriate written NHS consent form to obtain consent for children, adults and those patients who lacked the capacity to consent for treatment themselves. Where patients or children lacked the capacity to make their own decisions staff sought consent from their family members or representatives. Where this was not possible, staff made decisions about care and treatment in the best interests of the patient and involved the patient's representatives and other healthcare professionals. Arrangements were in place to ensure staff understood the requirements of the Mental Capacity Act 2005 and applied these when delivering care and treatment. Staff we spoke with confirmed they had received training in relation to mental capacity. They were aware of the procedures for gaining valid consent. Staff knew how and when to contact an Independent Mental Capacity Advocate (IMCA). An IMCA's role is to help particularly vulnerable people who lack the capacity to make important decisions about medical treatment. The service used a comprehensive mental capacity assessment form as part of their patient assessment. We spoke with one dentist who worked in the service they described Inspection Report Stephenson House October

7 a situation where a patient had been assessed as not being able to make an independent decision, for whom a decision had been made regarding tooth extraction. They explained how the appropriate people, including relatives and an IMCA had been involved in the decision making process. The decision had been clearly documented in the patient's notes and had been subsequently reviewed and updated. This meant where patients did not have the capacity to consent, the dentists acted in accordance with legal requirements. This ensured that vulnerable patients were treated with dignity and respect. Inspection Report Stephenson House October

8 Care and welfare of people who use services People should get safe and appropriate care that meets their needs and supports their rights Our judgement The provider was meeting this standard. Care and treatment was planned and delivered in a way that was intended to ensure patients' safety and welfare. Reasons for our judgement Patients' needs were assessed and care and treatment was planned and delivered in line with their individual treatment plan. During our visit clinical staff explained the information recorded at each patient's initial examination and at subsequent visits. Dentists recorded their examinations of soft tissues and teeth and other relevant observations. We saw that patient records contained a record of the examination and the findings. The dentist had also recorded information received from the patient, such as their medical and social history. Diagnostic tests, such as radiographs (x-rays), were carried out if they were clinically necessary. The justification for any diagnostic tests was clearly recorded in patient records. This meant that the dentist was aware of all factors which may influence the treatment or advice they offered. The service carried out intra-venous sedation and inhalation sedation for patients who were very nervous of dental treatment. Inhalation sedation (IS) is a form of sedation, a mixture of nitrous oxide and oxygen breathed through a nosepiece. Intra-venous sedation is a technique whereby a sedating drug is given to a patient by injection. Both forms of sedation help patients to feel relaxed and accept treatment. Patients remain conscious and are able to understand and respond to verbal commands.to assess the quality and safety in this area of clinical practice a Specialist Dental Advisor accompanied us during our visit. We found that care and treatment was planned and delivered in a way that ensured patients' safety and welfare. The Clinical Director described in detail the patient journey through a course of treatment involving intra-venous sedation from the initial assessment of the patient through to discharge following a session of dental treatment. We found that Intra-venous sedation was delivered according to the standards set out by Royal College of Anaesthetists and the Department of Health Standing Committee Guidelines in Conscious Sedation of We found that patients were appropriately assessed for sedation. The clinical records showed that all patients undergoing sedation had important checks made prior to sedation this included a medical history, height, weight and blood pressure. We saw that during the sedation procedure important checks were recorded which included pulse, blood pressure, breathing rates and the oxygen saturation of the blood. Dentists who carried out sedation Inspection Report Stephenson House October

9 were supported by appropriately trained nurses on each occasion. This meant that patients were treated safely and in line with current standards of clinical practice. There were arrangements in place to deal with foreseeable emergencies. There was a range of suitable equipment including an Automated External Defibrillator (AED), emergency drugs and oxygen available for dealing with medical emergencies. This was in line with the Resuscitation UK guidelines. The emergency drugs were all in date and the drugs were securely kept along with emergency oxygen in a central location known to all staff. The expiry dates of drugs and equipment was monitored using a daily check sheet which enabled the staff to replace out of date drugs and equipment in a timely manner. Staff had all taken part in cardio pulmonary resuscitation (CPR) training and those we spoke with were clear about their role should a medical emergency occur. A comprehensive recording system was available for the prescribing and recording of the medicines and drugs used in conscious sedation and other areas of clinical practise. The systems we viewed had been fully completed, provided an account of medicines prescribed, and demonstrated that patients were given their medicines as prescribed. We saw from a sample of clinical records that when drugs were prescribed the name of the drug, dose, timing and patient instructions were noted. The batch numbers and expiry dates for sedative drugs were always recorded. The sedative drugs used in conscious sedation belong to a group known as Schedule 3 and must be stored securely to prevent inappropriate access by members of the public and other unauthorised persons. We found these drugs were stored safely for the protection of patients. The storage cupboard used was found to be very tidy and orderly and an example of good practice. Inspection Report Stephenson House October

10 Cooperating with other providers People should get safe and coordinated care when they move between different services Our judgement The provider was meeting this standard. Patients' health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services. This was because the provider worked in co-operation with others. Reasons for our judgement Patients were referred to the priority dental service because their treatment needs could not be met by general dental services. For example; patients with learning disabilities, complex medical problems or severe mental health problems and children with severe behavioural management problems. We looked at the systems and procedures in place for accepting referrals from other health care professionals such as; general dental practitioners, care homes or health visitors. The service ensured that those people referring patients were informed by letter of any treatment carried out or if the patient did not meet their criteria for treatment. Reception staff told us that good relationships and communication had been established with a number of dental practices who referred patients to the service. This meant that information was shared in a way which enabled both services to meet the needs of their patients. We saw records which were kept to ensure the service could track a patient's progress from referral through to treatment or referral for general anaesthetic and discharge. The staff from Brookside Dental Clinic carried out treatment for patients under general anaesthetic. This treatment was carried out at the local general hospital alongside hospital staff, such as a consultant anaesthetist, operating theatre and recovery staff. Dental staff and hospital staff worked together to complete the treatment for patients. This meant that appropriate care planning took place and was co-ordinated to provide a seamless service for patients. The staff we spoke with told us, that there was effective collaboration and communication amongst all members of the multidisciplinary team (MDT) to support the planning and delivery of patient centred care. Effective MDT meetings, which involved dental staff, social workers, safeguarding leads, where required, ensured the patients' needs were fully explored. Issues discussed at the meetings included identification of the patient's existing care and treatment needs, relevant social or family issues, mental capacity as well as any support needed from other providers on discharge home. Inspection Report Stephenson House October

11 Patients' health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services. This was because the provider worked in co-operation with others. Inspection Report Stephenson House October

12 Safeguarding people who use services from abuse People should be protected from abuse and staff should respect their human rights Our judgement The provider was meeting this standard. People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Reasons for our judgement The service undertakes the treatment of groups of patients who may be vulnerable to being abused; these include children, the frail elderly and patients with learning disabilities. We found the dental service protected patients from abuse and avoidable harm as staff were confident about reporting serious incidents or concerns and providing information to the Clinical Director or Dental Operations Manager. All staff we spoke with were aware of the safeguarding policy and had received training at the appropriate level in relation to safeguarding vulnerable adults and children. The Clinical Director showed us the service's mandatory training records which showed staff attendance at Safeguarding Vulnerable Adults was 95% and Safeguarding Children 99%. Staff we spoke with were aware of their responsibilities to report any concerns and understood who they should report any concerns to. We saw that contact details of the child and adult safeguarding teams were displayed at various points in the department. The service had two members of staff who acted as safeguarding champions. They attended meetings with other health care professionals from the Central and North West London NHS Foundation Trust (CNWL) to discuss safeguarding related topics. Information from the trust meetings was fed back to other staff members at team meetings. We saw the minutes of a staff meeting where safeguarding had been discussed. There was a record of the Trust's policy to discuss cases with local safeguarding teams when vulnerable patients had missed two general anaesthetic appointments. This meant that systems were in place to protect vulnerable patients at risk of neglect. Inspection Report Stephenson House October

13 Assessing and monitoring the quality of service provision The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care Our judgement The provider was meeting this standard. The provider had an effective system to regularly assess and monitor the quality of service that people receive. Reasons for our judgement Patients who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. The service sought feedback from their patients in the form of a satisfaction survey. The most recent survey had taken place between December 2013 and February The results for Brookside Dental Clinic had formed part of the overall analysis of patient satisfaction for Buckinghamshire Priority Dental Service (BPDS), all responses were generally positive. The provider was able to show us the comments that patients had made about each of the dental clinics involved in the survey. This meant that they were able to act on comments made specifically by patients of Brookside Dental Clinic. We saw that the results of the survey were displayed in the waiting room along with details of how the service had responded to patients' comments. A comments box was available in the waiting room for patients to use. Comment forms were also available in an easy read format to meet the needs of the patients that used the service. The practice held regular staff meetings where changes to the practice or relevant information were passed on to staff. One of the dental nurses we spoke with told us that staff were encouraged to add items for discussion to the agenda. We saw minutes of a staff meeting where results of quality monitoring reports had been discussed. Staff told us incidents, accidents or near misses were reported on the Central and North West London NHS Foundation Trust's (CNWL) risk management system which enabled them to identify any trends. The Operations Manager of BPDS attended an incident group each quarter where representatives from across the Trust met to share and discuss incidents. This meant that learning from incidents took place. We were shown a radiation protection file. This file contained all the necessary documentation relating to the maintenance of the x-ray equipment. These included the critical examination packs for each x-ray machine. These are tests which are carried out to ensure the x-ray machine is operating safely and efficiently. A copy of the local rules was also available for inspection. Patient records showed when each x-ray was taken it was justified and reported, the x-ray was quality assessed and then graded for quality. This Inspection Report Stephenson House October

14 meant that the practice was acting in accordance with national radiological guidelines. The measures described meant that patients and staff were protected from unnecessary exposure to radiation. The service had processes in place to monitor the quality and safety of patient care. Before a new dentist could begin providing sedation, even though they may be experienced in sedation, they were required to demonstrate their competency. They were required to complete a series of tests as well as being observed by the Clinical Lead in sedation before being allowed to provide sedation to patients unsupervised. The Clinical Director reported that there have been no adverse incidents in relation sedation. This meant that patients are being treated safely and in line with current standards of clinical practice. There was evidence of a number of audits of the BPDS. For example an audit of patient records, infection prevention and control and hand hygiene. These were carried out across the organisation to ensure continuity of safe patient care. BPDS had nominated audit leads who set objectives and topics for audit. These were in addition to those audits identified as mandatory by the Trust which were fed into the Trust's clinical governance framework. This meant that the service monitored the quality of their patient care both as an individual clinic and as an organisation. Inspection Report Stephenson House October

15 About CQC inspections We are the regulator of health and social care in England. All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations We regulate against these standards, which we sometimes describe as "government standards". We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming. There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times. When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place. We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it. Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to reinspect a service if new concerns emerge about it before the next routine inspection. In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers. You can tell us about your experience of this provider on our website. Inspection Report Stephenson House October

16 How we define our judgements The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection. We reach one of the following judgements for each essential standard inspected. This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made. Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action. We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete. Enforcement action taken If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range of actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people. Inspection Report Stephenson House October

17 How we define our judgements (continued) Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact. Minor impact - people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly. Moderate impact - people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly. Major impact - people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards. Inspection Report Stephenson House October

18 Glossary of terms we use in this report Essential standard The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations These regulations describe the essential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are: Respecting and involving people who use services - Outcome 1 (Regulation 17) Consent to care and treatment - Outcome 2 (Regulation 18) Care and welfare of people who use services - Outcome 4 (Regulation 9) Meeting Nutritional Needs - Outcome 5 (Regulation 14) Cooperating with other providers - Outcome 6 (Regulation 24) Safeguarding people who use services from abuse - Outcome 7 (Regulation 11) Cleanliness and infection control - Outcome 8 (Regulation 12) Management of medicines - Outcome 9 (Regulation 13) Safety and suitability of premises - Outcome 10 (Regulation 15) Safety, availability and suitability of equipment - Outcome 11 (Regulation 16) Requirements relating to workers - Outcome 12 (Regulation 21) Staffing - Outcome 13 (Regulation 22) Supporting Staff - Outcome 14 (Regulation 23) Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10) Complaints - Outcome 17 (Regulation 19) Records - Outcome 21 (Regulation 20) Regulated activity These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided. Inspection Report Stephenson House October

19 Glossary of terms we use in this report (continued) (Registered) Provider There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'. Regulations We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations Responsive inspection This is carried out at any time in relation to identified concerns. Routine inspection This is planned and could occur at any time. We sometimes describe this as a scheduled inspection. Themed inspection This is targeted to look at specific standards, sectors or types of care. Inspection Report Stephenson House October

20 Contact us Phone: Write to us at: Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Website: Copyright Copyright (2011) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Inspection Report Stephenson House October

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