We carried out an announced comprehensive inspection on 3 November 2015 as part of our regulatory function where a breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach.

We carried out a focussed review on 29 September 2016 to check whether the practice had taken action to address a breach of Regulation 17(1) and (2)(a)(b)(c)(f) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This report only covers our findings in relation to those requirements. We have not revisited Mr Imran Azmat – Birchfield Road for this review because the registered provider was able to demonstrate that they were meeting the standards without the need for a visit. You can read the report from our previous comprehensive inspection by selecting the ‘all reports’ link for Mr Imran Azmat – Birchfield Road on our website at www.cqc.org.uk

Our findings were:

Are services well-led?

We found that this practice was providing well-led care in accordance with the relevant regulations.

Our key findings were:

• Overall we found that sufficient action had been taken to address the shortfalls identified at our previous inspection and the provider was now compliant with the regulation.

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

• Review the practice’s systems for completing checks on emergency equipment and medicines giving due regard to guidelines issued by the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.

• Review the current legionella risk assessment and implement the required actions, giving due regard to 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 infections and related guidance

We carried out an announced comprehensive inspection on 3 November 2015 as part of our regulatory function where a breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach.

We carried out a focussed review on 29 September 2016 to check whether the practice had taken action to address a breach of Regulation 17(1) and (2)(a)(b)(c)(f) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This report only covers our findings in relation to those requirements. We have not revisited Mr Imran Azmat – Birchfield Road for this review because the registered provider was able to demonstrate that they were meeting the standards without the need for a visit. You can read the report from our previous comprehensive inspection by selecting the ‘all reports’ link for Mr Imran Azmat – Birchfield Road on our website at www.cqc.org.uk

Our findings were:

Are services well-led?

We found that this practice was providing well-led care in accordance with the relevant regulations.

Our key findings were:

• Overall we found that sufficient action had been taken to address the shortfalls identified at our previous inspection and the provider was now compliant with the regulation.

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

• Review the practice’s systems for completing checks on emergency equipment and medicines giving due regard to guidelines issued by the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.

• Review the current legionella risk assessment and implement the required actions, giving due regard to 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 infections and related guidance

Before our visit told, we told the provider that we were coming. The provider is also the practising dentist at the practice. We asked the provider to inform people who would be visiting the dentist on the day of our visit and advice them that we may speak with them.

During our visit, we spoke with one person using the service, two dental nurses, the provider and another dentist. Following our visit, we spoke with five people on the telephone to seek their views about the service provided. We looked at the records for five people who had used the service. It was not appropriate to speak to more then one person during our visit.

People were complimentary about the service and said that the staff made them feel welcome. They told us any treatment they had was fully explained to them. One person told us “I have been going to this practice since I was 10 years old I am now 80 so must it be good.“ and they added “It is very well run, both now and by the predecessors.’’

One person told us “I have recommended the practice to friends and family and now they all use the practice, it’s because it’s so friendly and you get treatment. I am impressed with the treatment” and “I am very satisfied.’’

All of the people we spoke to told us that their treatments options were explained to them and they had time to consider if they wanted to go ahead with the advice given to them by the dentist. We saw that records were detailed about the choices of treatments people had. They told us that appointments were made to suit them and they were seen quickly if they experienced any problems.

Staff were not supported in all areas. Formal, supervision did not take place. Staff were not sure of what to do in the event of possible signs of abuse and reporting this to the appropriate authority. Staff had not received recent training in safeguarding people and improvements are needed in this outcome.

There were systems in place to monitor how the practice was run, to ensure people receive a quality service.