We carried out this announced inspection on 11 March 2019 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.

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

Are services effective?

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

Are services caring?

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

Are services responsive?

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

Are services well-led?

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

Background

Elsey and Elsey Dental Practice is in South Cerney and provides NHS treatment for children only and private treatment for adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces, are available near the practice.

The dental team includes one dentist, one specialist orthodontist, two orthodontic therapists, one dental hygiene therapist, two dental hygienists, two dental nurses and one receptionist. 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 Elsey and Elsey Dental Practice is the principal dentist.

On the day of inspection, we collected 29 CQC comment cards filled in by patients and spoke with two other patients.

During the inspection we spoke with one dentist, one orthodontist, two dental nurses, one dental hygiene therapist, 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 and Thursday 8.30am to 5.30pm

Tuesday and Wednesday 9am to 4pm

Friday 8.30 to 4pm

Our key findings were:

• The practice appeared clean and well maintained.
• The provider had infection control procedures which mostly reflected published guidance.
• Staff knew how to deal with emergencies. Not all appropriate medicines and life-saving equipment were available.
• The practice had some systems to help them manage risk to patients and staff but these required improvements.
• The provider had safeguarding processes. Staff knew their responsibilities for safeguarding vulnerable adults and children.
• The provider had staff recruitment procedures.
• 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.
• Staff were providing preventive care and supporting patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• The provider did not have a culture of continuous improvement.
• Staff felt involved, supported and worked well as a team.
• The provider did not ask staff and patients for feedback about the services they provided.
• The provider had an appropriate complaint policy.
• The provider had suitable information governance arrangements.

We identified regulations the provider was not complying with. They must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulation the provider is not meeting are at the end of this report.

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

• Review the practice processes and systems for seeking and learning from patient feedback with a view to monitoring and improving the quality of the service.

• Review the practice arrangements for ensuring good governance and leadership are sustained in the longer term.
• Review the current staffing arrangements to ensure all dental care professionals are adequately supported by a trained member of the dental team when treating patients in a dental setting taking into account the guidance issued by the General Dental Council.

One person told us they had been treated by three other dentists before registering with the practice. They said that the dentist they saw now was “ahead of any of them”. They told us that their treatment was pain free, appointments were always made to suit their individual preference for time and they never had to wait for treatment.

A customer satisfaction survey was conducted and only 60% of respondents were aware of the complaints policy. In response to this the practice displayed information about how to make a complaint at the reception desk.

The practice had level access to the reception and waiting area and there was a treatment room on the ground floor for use by those with restricted mobility.

There were policies relating to child protection and safeguarding vulnerable adults. We saw forms in place for making referrals.

We noted that the practice infection control policy made reference to cleaning of work services and equipment, decontamination of dental instruments, hand hygiene and the wearing of protective equipment. In addition there was guidance for minimising blood borne virus and blood spillage.

We spoke with staff who told us they felt supported by the dentists. They said that Elsey and Elsey Dental Practice was a “nice place to work”.

There were policies relating to data protection, keeping patient records and confidentiality.