We carried out this announced inspection on 30 January 2018 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 they provided information which we took into account.

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.

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

The dental team includes 6 dentists, 1 dental nurse, 4 trainee dental nurses, 1 receptionist and two practice managers. The practice has four treatment rooms.

On the day of inspection we collected 34 CQC comment cards filled in by patients and spoke with two other patients. This information gave us a mostly positive view of the practice. However there were some comments regarding the problems of getting through on the phone to make an appointment, long waiting times for appointments for treatment and overrunning appointment times.

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

The practice is open:

Saturday Flexible

Sunday Closed

Monday 8.30am–6pm

Tuesday 8:30am–6pm

Wednesday 8.30am–8pm

Thursday 8:30am–6pm

Friday 8:30am–5pm

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.

Our key findings were:

• The practice appeared mostly clean and well maintained.
• The practice had infection control procedures which reflected published guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
• 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.
• 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 needs reviewing to meet 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 systems in place for environmental cleaning taking into account current national guidelines.
• Review the suitability of the premises and ensure all parts were fit for the purpose for which they are being used.
• Review its responsibilities to the needs of people with a disability, including those with hearing difficulties and the requirements of the Equality Act 2010.
• Review availability of an interpreter services for patients who do not speak English as a first language.
• Review practice's recruitment procedures to ensure that appropriate background checks are completed prior to new staff commencing employment at the practice.
• Review the protocol for completing accurate, complete and detailed records relating to employment of staff. This includes making appropriate notes of verbal reference taken and ensuring recruitment checks, including references, are suitably obtained and recorded.
• Review the current performance review systems in place and have an effective process established for the on-going assessment and supervision of all staff.
• Review the practice’s protocols for the use of rubber dam for root canal treatment taking into account guidelines issued by the British Endodontic Society.
• Review staff training to ensure that all of the staff had undergone relevant training, to an appropriate level, in the safeguarding of children and vulnerable adults.
• Review the protocols and procedures to ensure staff are up to date with their mandatory training and their Continuing Professional Development (CPD)
• Review the practice’s audit protocols to ensure audits of various aspects of the service, such as radiography and infection prevention and control are undertaken at regular intervals to help improve the quality of service. Practice should also ensure that where appropriate audits have documented learning points and the resulting improvements can be demonstrated.