We carried out this announced inspection on 2 May 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. We did not receive any information of concern from them.

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

M Foster Dental Surgeon Limited is in Rotherham and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and pushchairs. Car parking is available near the practice.

The dental team includes three dentists, six dental nurses (one of whom is a trainee), a decontamination operative, one dental hygienist and a practice 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 M Foster Dental Surgeon Limited was the principal dentist.

On the day of inspection we received feedback from 50 patients. This information gave us a positive view of the practice.

During the inspection we spoke with two dentists, two dental nurses, the decontamination operative, the dental hygienist 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 to Friday from 8:00am to 5:00pm. They are closed between 12:30pm and 2:00pm for lunch.

Our key findings were:

• The practice was clean and well maintained.
• The practice had infection control procedures in place. The storage of instruments did not reflect current guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available with the exception of buccal midazolam.
• The practice had systems to help them manage risk. Improvements were required to the risks associated with fire.
• 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 patients for feedback about the services they provided.
• The practice dealt with complaints positively and efficiently.
• Governance systems were effective.

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

• Review the security of prescription pads in the practice and ensure there are systems in place to monitor and track their use.
• Review the practice’s fire risk assessment and ensure regular fire drills are carried out.
• Review the storage of sterilised instruments giving due regard to guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices.
• Review the practice’s procedure for risk assessing staff who are non-responders to the Hepatitis B vaccination.
• Review the local rules in the upstairs surgery to reflect the result of the last routine test.
• Review the practice’s audit protocols of infection prevention and control to ensure it is completed every six months.

People who used the service told us they were asked to consent to treatment after a full explanation of the proposed procedures had been given to them. We found that the practice had appropriate policies on consent which were understood and followed by staff.

People told us they were satisfied with the care they received. They also told us they were given clear information about the procedures being undertaken. We found that people’s needs were assessed and treatment was planned and delivered in line with their individual treatment plan.

People told us they were treated in a clean environment. We found that people were protected from the risk of infection as there were effective systems in place to reduce the risk and spread of infection.

People told us staff seemed competent in their job and knew what they were doing. We found that staff received an appropriate level of training and professional development.

People who used the service told us they knew who to contact if they wished to make a complaint. There was a complaints procedure in place and staff were aware of their responsibilities to report complaints so they could be formally investigated.