We carried out this announced inspection on 18 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 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

Mapplewell Dental Centre is in Mapplewell, Barnsley and provides private treatment to adults and children.

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

The dental team includes two principal dentists, three associate dentists, four dental nurses (one of whom was the governance lead), a dental hygienist and a dental therapist, three receptionists and the practice cleaner. The team is supported by the practice manager. In addition; the team is visited on an occasional basis by an oral and maxillofacial surgeon who has a special interest in implant dentistry. 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 Mapplewell Dental Centre is one of the principal dentists.

On the day of inspection, we collected 24 CQC comment cards filled in by patients. All comments received reflected positively on the service.

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

The practice is open: Monday, Wednesday and Friday 9am – 1pm and 2pm – 6pm, Tuesday and Thursday 9am – 1pm and 2pm – 5.30pm.

Our key findings were:

• The practice appeared clean and well maintained.
• The provider had infection control procedures which reflected published guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
• Improvements could be made to the equipment validation process for the vacuum steriliser.
• The practice had systems to help them manage risk to patients and staff. The process of assessing the risks associated with the use of hazardous materials could be improved.
• The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The provider had thorough staff recruitment procedures.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• There was no log in place to ensure referrals to other service providers were actively monitored.
• 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 had effective leadership and culture of continuous improvement.
• Staff felt involved and supported and worked well as a team.
• The provider asked staff and patients for feedback about the services they provided.
• The provider dealt with complaints positively and efficiently.
• The provider had suitable information governance arrangements.

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

• Review the practice's policy for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure individual risk assessments are undertaken.
• Review the practice’s protocols for the validation of dental equipment and ensure it is carried out in line with the manufacturer’s instructions.
• Review the practice’s processes to ensure a log is in place to actively monitor patient referrals to other service providers.