We carried out this announced inspection on 7 December 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 carried out by two CQC inspectors (one of whom was also a specialist dental adviser).

We told the NHS England area team that we were inspecting the practice. They did not provide any information for us to take into account.

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

Mr Imran Azmat – Pershore Road dental practice is in Stirchley and provides NHS and private treatment to patients of all ages.

The practice is situated on a busy street and the provider has been unable to provide level access for people who use wheelchairs and pushchairs. Car parking spaces are available near the practice but there are not any dedicated spaces immediately adjacent to the practice.

The dental team includes two dentists, two dental nurses and one receptionist. The practice has one treatment room.

The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.

On the day of inspection we collected 32 CQC comment cards filled in by patients. This information gave us a positive view of the practice.

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

The practice is open between 9am and 5:30pm from Monday to Friday. The practice offers extended opening hours on Wednesdays when it remains open to patients until 7pm.

Our key findings were:

• The practice was clean and well maintained.
• The practice had infection control procedures which reflected published guidance. We identified some necessary improvements and the practice responded promptly to resolve these.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available but some necessary improvements were required.
• The practice had systems to help them manage risk.
• The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
• The practice had staff recruitment procedures although these had not been followed for the most recently appointed staff member with respect to the documentation of references.
• 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. Reception staff did not lock the computer screen when it was unattended; however, they responded promptly when this was brought to their attention.
• 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 the practice’s current Legionella risk assessment and implement the required actions taking into account guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and have regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.’
• Review availability of equipment to manage medical emergencies taking into account guidelines issued by the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.
• Review stocks of medicines and equipment and the system for identifying, disposing and replenishing of out-of-date stock.
• Review the practice’s systems for analysing the results of audits and reviews to identify, share and act on areas for improvement where appropriate.
• Review all policies and ensure they contain relevant information which is specific to the practice.
• Review the practice’s induction procedures and ensure they are documented for newly recruited staff in future.

Our visit was discussed and arranged with the practice in advance. This was to ensure that we had time to see and speak to staff working at the practice, as well as people registered with the practice.

During the inspection we spoke with one dentist, one dental nurse and the receptionist and observed a consultation. After our inspection visit, we spoke by telephone with seven people who were registered with the practice to ask them about their experiences of the service.

The people we spoke with were complimentary about the service they had received. Their comments included, “Customer service is brilliant, she (the dentist) is the nicest person, very professional” and “I’ve been to other dentists, she is the gentlest one, very pleasant, very efficient, very personal (service).” People told us they were given the information they needed to be able to make an informed decision about their treatment.

Staff received a range of training so that they had up to date knowledge and skills in order to treat people safely when they attended the practice.

People told us that the practice was clean and tidy and we found that the provider had effective infection control procedures in place. This meant the risk of infection for people using the service was minimised.

There were systems in place that ensured people using the service were asked their views about the service so the provider could use the information to improve.