We carried out this announced inspection on 12 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

Poplar’s Dental Practice is in Yarm, North Yorkshire and provides NHS and private treatment to adults and children.

The dental practice is located on the first and second floor of a building, with the entrance on the ground floor. A stairlift is available from the ground to the first floor for those who may need assistance ascending the stairs. Car parking spaces are available near the practice.

The dental team includes a principal dentist, one associate dentist, a visiting specialist oral surgeon, the practice manager, five dental nurses (one of whom is also the reception manager), a sterilisation technician, a dental therapist and a dental hygienist. The practice has four treatment rooms.

The practice is owned by a partnership 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. At the time of inspection, a registered manager was not in place at Poplar’s Dental Practice and there were changes to the partnership a few years prior which were not notified to us. We were assured by the principal dentist that they would ensure review their registration and make the appropriate changes.

On the day of inspection, we collected 49 CQC comment cards filled in by patients. These provided a positive view of the practice.

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

The practice is open:

Monday, Wednesday and Friday 8.45am to 5pm

Tuesday and Thursday 8.45am to 7pm

Saturday once a month 9am to 12.30pm

Our key findings were:

• The practice appeared clean and a refurbishment programme was in place to improve the overall practice.
• The practice had infection control procedures which reflected published guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were not available in accordance with national guidelines. A child’s self-inflating and airway were not present; these were ordered on the inspection day.
• The practice had systems to help them manage risks. The practice needed to review their systems for risks associated with Legionella, radiation protection and fire.
• The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
• The practice had thorough staff recruitment procedures.
• 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 practice had effective leadership and culture of continuous improvement. Staff were welcoming of our feedback and took immediate measures to implement any necessary actions.
• 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 arrangements for receiving and responding to patient safety alerts, recalls and rapid response reports issued by the Medicines and Healthcare products Regulatory Agency, the Central Alerting System and other relevant bodies, such as Public Health England.
• Review the availability of equipment in the practice to manage medical emergencies taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.
• Review the practice's Legionella risk assessment and ensure it is undertaken by a competent person, taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.’
• Review the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment.
• Review the fire safety risk assessment and ensure that ongoing fire safety management is effective, in particular reference to the compressor room.
• Review the providers registration and registration conditions to ensure the regulated activities at Poplar’s Dental Practice) are managed by an individual who is registered as a manager.

We spoke with one person who used the service. This person told us they were happy with the service and always managed to get a convenient appointment. This person said, “The staff are very nice and approachable.”

We looked at patient questionnaires and suggestion sheets completed by people who used the service. From the questionnaires we looked at all people agreed or strongly agreed that they were treated with dignity and respect and were given enough information about their treatment and costs. From the suggestion sheets we looked at, one person stated, ‘Always a good experience, pleasant, friendly staff’, another stated, ‘I am happy with the service.’

We found that people who used the service had their privacy and dignity respected.

We found that people were protected from the risk of infection as care was delivered in a clean and hygienic environment.