We carried out this announced inspection on 15 August 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a CQC inspector who was supported by a specialist dental adviser.

We told the NHS England area team and Healthwatch that we were inspecting the practice. They did not provide any information.

To get to the heart of patients’ experiences of care and treatment, 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 we look at during the inspection.

Our findings were:

Are services safe?

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

Are services effective?

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

Are services caring?

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

Are services responsive?

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

Are services well-led?

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

Background

Coulsdon Dental Practice is in Coulsdon and provides NHS and private treatment to patients of all ages.

There is level access for people who use wheelchairs and pushchairs. Parking is available on surrounding streets for a fee. Local transport links were good.

The dental team includes three dentists, one dental nurse, three trainee dental nurses, two dental hygienists, two receptionists and a practice manager. The practice has 3 treatment rooms, two offices, two decontamination rooms, an X-ray room, staff room and reception and patient waiting area.

The practice is owned by a company and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run. At the time of the inspection the practice did not have a registered manager in post however the practice manager had made an application and was waiting for it to be processed.

On the day of inspection we collected one CQC comment card filled in by a patient. This information gave us a positive view of the practice.

During the inspection we spoke with one dentist, two trainee dental nurses, one dental hygienist, one receptionist and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open: Monday, Wednesday and Fridays from 8.00am to 6.30pm; Tuesday and Thursday from 8.00am to 8.00pm and Saturdays from 9.00am to 1.00pm.

Our key findings were:

• The practice was clean and well maintained.
• The practice had infection control procedures which reflected published guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
• The practice had systems to help them manage risk.
• The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
• The organisation had thorough staff recruitment procedures. However they were not always followed.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• The appointment system met patients’ needs.
• The practice had effective leadership. Staff felt involved and supported and worked well as a team. Leadership structures at the organisation level were less visible.
• The practice asked staff and patients for feedback about the services they provided.
• The practice dealt with complaints positively and efficiently.

There were areas where the provider could make improvements. They should:

• Review the practice's recruitment policy and procedures to ensure accurate, complete and detailed records are maintained for all staff.
• Review the staff supervision protocols and ensure an effective process is established for the on-going appraisal of all staff.

People who use the service told us that staff at the practice were very friendly and made them feel at ease. They told us they received thorough examinations and everything including their treatment and the cost of treatment was explained to them. They told us they were able to make appointments when needed.

They told us their privacy and confidentiality was respected and the practice was always comfortable and clean and tidy.

They told us they would know what to do if they needed to make a complaint.

They told us they were very satisfied with their overall experience when attending the practice.

One person told us that sometimes it could be a bit noisy in the treatment room at the front of the building.