We carried out a comprehensive inspection of this practice on 15 September 2015. Breaches of legal requirements were found. After the inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to person-centred care.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Bentley Road on our website at www.cqc.org.uk.

Our findings were:

Are services effective?

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

Background

Bentley Road Dental Practice is situated in the Bentley area of Doncaster. It offers mainly NHS treatment to patients of all ages but also offers private dental treatments. The services include preventative advice, treatment and routine restorative dental care.

The practice has six surgeries, two decontamination rooms, an X-ray room, two waiting areas and a reception area. Treatment and waiting rooms are on the ground and first floor of the premises.

There are seven dentists, a dental hygienist, six dental nurses, one receptionist and a practice manager.

The opening hours are Monday to Friday 9-00am to 5-30pm.

The practice manager is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is run.

Our key findings were:

• One of the dentists had taken the role of clinical lead.
• The dentists generally followed guidance provided by the Faculty of General Dental Practice in the Selection Criteria for Dental Radiography.

We carried out an announced comprehensive inspection on 15 September 2015 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 not 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 providing well-led care in accordance with the relevant regulations.

Background

Bentley Road Dental Practice is situated in the Bentley area of Doncaster. It offers mainly NHS treatment to patients of all ages but also offers private dental treatments. The services include preventative advice, treatment and routine restorative dental care.

The practice has six surgeries, two decontamination rooms, an X-ray room, two waiting areas and a reception area. Treatment and waiting rooms are on the ground and first floor of the premises.

There are six dentists, a dental hygienist, six dental nurses, one receptionist and a practice manager.

The opening hours are Monday to Friday 9-00am to 5-30pm.

The practice manager is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is run.

On the day of inspection 57 people provided feedback. The patients who provided feedback were positive about the care and treatment they received at the practice. They told us they were involved in all aspects of their care, found the staff to be friendly and they were treated with dignity and respect.

Our key findings were:

• The practice had systems in place to assess and manage risks to patients and staff including infection prevention and control, health and safety and the management of medical emergencies.
• There were clearly defined leadership roles within the practice and staff told us that they felt supported, appreciated and comfortable to raise concerns or make suggestions. Staff received training appropriate to their roles.
• Patients told us they were treated with kindness and respect by staff. Staff ensured there was sufficient time to explain fully the care and treatment they were providing in a way patients understood. Patients commented they felt involved in their treatment and that it was fully explained to them.
• Patients were able to make routine and emergency appointments when needed. The practice had a complaints system in place and there was an openness and transparency in how these were dealt with.

We identified regulations that were not being met and the provider must:

• Review the practice’s protocols for the taking of X-rays giving due regard to the Faculty of General Dental Practice (FGDP) guidance on the “Selection Criteria for Dental Radiography”.

You can see full details of the regulations not being met at the end of this report.

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

• Review the practice’s protocols for recording in the patients’ dental care records or elsewhere the reason for taking theX-rays and reporting on the X-rays giving due regard to the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2000.
• Review the practice's protocols for completion of dental records with regards to documenting discussions about treatment options.
• 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.
• Take action to ensure the appointment books are not visible on the reception desk

Review the practice’s protocol for undertaking regular audits of dental care records.

This visit was a follow up to determine compliance with compliance actions issues at our inspection in April 2013. At this visit we did not speak to any people who received a service.

Evidence showed people were protected from the risk of infection because appropriate guidance had been followed.

We saw that appropriate checks were undertaken before staff began work.

The practice had an effective well organised system to regularly assess and monitor the quality of service that people received. The practice had a complaints policy and took account of complaints and comments to improve the service. People were regularly asked to give feedback in the form of questionnaires. We also saw the results of the questionnaires carried out over the last year, which were mostly positive.

People's needs were assessed and treatment was planned and delivered in line with their individual treatment plan. The five people we spoke with commented positively about the care and treatment they had received. They told us it was easy to make appointments and waiting times at the practice were minimal.

There were not effective systems in place to reduce the risk and spread of infection. We saw people were not always protected from the risk of infection because appropriate guidance was not available and was not followed. We saw areas of the practice that were not clean or well maintained.

We saw that appropriate checks were not always undertaken before staff began work.

Staff received professional development. We saw they had accessed various training so they could meet people’s needs and maintain their qualifications. However some training had not been accessed, staff were not supervised and appraisals were over due.

The practice had a system to regularly assess and monitor the quality of service people received. However some areas had not been properly monitored so areas of concern had not been identified.