We carried out an announced comprehensive inspection on 3 August 2016 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 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

I J Kellam Ltd is a dental practice located in the Martinwells Centre in Edlington, near Doncaster. The practice provides a mix of NHS and private treatment for both adults and children. The practice had four dental treatment rooms and a separate decontamination room for cleaning, sterilising and packing dental instruments, a reception and two waiting areas.

The practice is open between the hours of 8am and 6pm; opening and closing hours varying from day to day throughout the week. The practice has two full time dentists, a foundation dentist and two part time dentists and they are supported by five dental nurses, a receptionist and a practice manager.

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.

Before the inspection we sent CQC comment cards to the practice for patients to complete to tell us about their experience of the practice, 16 patients provided positive feedback of the services provided, caring nature of all staff, the cleanliness and quality of care during treatment.

Our key findings were:

• Staff had received safeguarding training, staff knew how to recognise signs of abuse and some were aware of how to report it. A safeguarding policy was in place and staff would be directed to the local safeguarding team from within the policy.
• There were sufficient numbers of suitably qualified staff to meet the needs of patients.
• Staff had been trained to manage medical emergencies.
• Patient care and treatment was planned and delivered in line with evidence based guidelines, best practice and current regulations.
• Patients received clear explanations about their proposed treatment, costs, benefits and risk and were involved in making decisions about it.
• Patients were treated with dignity and respect and confidentiality was maintained.
• There was a complaints system in place.
• The practice sought feedback from patients about their services.
• The practice had dental engagement with the Patient Participation Group (PPG) for a project to improve the uptake of dental services.

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

• Review the practice management responsibilities to encourage broader ownership of more critical elements of practice and patient safety.
• Review the practice Significant Event incident reporting procedures.
• Review the practice responsibilities in regards to the Control of Substance Hazardous to Health (COSHH) Regulations 2002 and implement COSHH Assessments for all Safety Data Sheets held.
• Review the practice’s decontamination equipment daily maintenance processes giving due regard to manufacturer’s instructions and to guidelines issued by the Department of Health – Health Technical Memorandum 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008:’Code of Practice about the prevention and control of infection and related guidance in regards to validation of equipment.
• Review the practice’s audit processes to document learning points that are shared with all relevant staff and ensure that the resulting improvements can be demonstrated as part of the audit process.
• Review the practice arrangements to ensure all administrative systems and procedures are available to staff, cascaded and understood to remain current with policy changes and updates.

We found that people's views and experiences were taken into account in the way the service was provided and delivered in relation to their care. We spoke with nine people who used the service to gain their views. Everyone gave very positive feedback about the standard of the service. They said they were treated with respect and in a way that upheld their privacy. One person said, "The staff very friendly and helpful.”

People experienced care, treatment and support that met their needs and protected their rights. We saw evidence that people received safe and appropriate care that met their needs.

People who used the service were protected from the risk of infection. Processes were in place to ensure staff were aware of infection control procedures, through a program of training.

The information reviewed at inspection showed that good practice was followed in supporting and training staff. All of the people we spoke with said the staff were friendly and helpful.

The provider had an effective system in place to regularly assess and monitor the quality of service that people received.