We carried out this announced inspection on 14 June 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.

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

Foley Park Dental Practice is situated in a converted residential building in Kidderminster, Worcestershire. It provides NHS and private treatment to patients of all ages. The practice’s clinical team comprises of the principal dentist, a visiting implantologist, a dental hygienist, three qualified dental nurses and a trainee dental nurse. The clinical team are supported by a receptionist.

The practice is owned by the principal dentist who is registered with the Care Quality Commission (CQC) as 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.

The building is split over two storeys. The ground floor of the practice consists of a reception area, a waiting room, a staff room / kitchen and two dental treatment rooms. On the first floor there is a decontamination room for the cleaning, sterilising and packing of dental instruments. At the time of our visit the practice was undergoing building works to the first floor to include an additional treatment room and an office. The building has level access for patients who use wheelchairs and pushchairs.

On the day of inspection we collected 12 CQC comment cards filled in by patients, spoke with a patient and reviewed the practice online survey comments. This information gave us a positive view of the practice.

During the inspection we spoke with the principal dentist and two dental nurses. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday: 8.30am – 5pm

Tuesday: 9am – 8pm

Wednesday: 9am – 6pm

Thursday: 8.30am – 6pm

Friday: 9am – 1pm

Saturday: By appointment only

Our key findings were:

• The practice was clean and well maintained.
• The practice had infection control procedures which reflected published guidance, with the exception of completing infection control audits on a six monthly basis. The practice completed these every nine months.
• Staff knew how to deal with emergencies.
• The practice had some systems to help them manage risk. We found the practice had not completed a fire risk assessment or legionella risk assessment including a written waterline management scheme. A legionella risk assessment was scheduled to be completed on the 28 June 2017.
• 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.
• 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. They should:

• Review monitoring processes and protocols to ensure effective monitoring of incident procedures, emergency medicines and equipment, legionella procedures and fire procedures including the five year fixed wire testing.