We carried out this announced inspection on 3 November 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a CQC inspector 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 of concern.

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

DDS Cleethorpes provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and pushchairs. Car parking spaces, including one for patients with disabled badges are available near the practice.

The dental team includes five dentists, seven dental nurses (who also cover reception duties), one dental hygienist, one receptionist, a practice manager and a regional manager. The practice has three treatment rooms.

The practice is owned by a company and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run. The registered manager at DDS Cleethorpes was the practice owner.

On the day of inspection we collected 12 CQC comment cards filled in by patients. This information gave us a positive view of the practice.

During the inspection we spoke with two dentists, three dental nurses, the practice manager and the regional manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Friday from 9:00am to 5:00pm

Our key findings were:

• The practice was clean and well maintained.
• Improvements could be made to the process for the notification of incidents to the CQC.
• 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 practice had thorough staff recruitment procedures.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Improvements could be made to the process for urgent referrals.
• 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.
• 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 and should:

• Review the practice’s system for notifying reportable incidents to the CQC.
• Review the practice’s protocols for ensuring urgent referrals are sent in a timely manner.
• Review the storage of products identified under Control of Substances Hazardous to Health (COSHH) 2002 Regulations to ensure they are stored securely.