We undertook a focused follow up inspection of Town Moor Dental Care on the 17 September 2018. This inspection was carried out to review in detail the actions taken by the registered provider to improve the quality of care and to confirm that the practice was now meeting legal requirements.

The inspection was led by a CQC inspector who was supported by a specialist dental adviser.

We undertook a comprehensive inspection of Town Moor Dental Care on 29 May 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We found the registered provider was not providing well led care in accordance with the relevant regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can read our report of that inspection by selecting the 'all reports' link for Town Moor Dental Care on our website www.cqc.org.uk.

When one or more of the five questions are not met we require the service to make improvements and send us an action plan. We then inspect again after a reasonable interval, focusing on the area where improvement was required.

As part of this inspection we asked:

• Is it well-led?

Our findings were:

Are services well-led?

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

The provider had made improvements in relation to the regulatory breaches we found at our inspection on 29 May 2018.

Background

Town Moor Dental Care is in Doncaster and provides private treatment to adults and children. Entry into the practice is via a single step. Entry assistance is available if required for people who use wheelchairs and pushchairs. Car parking spaces are available at the practice.

The dental team includes the principal dentist and two dental nurses, one of whom is a trainee. A dentist who specialises in endodontics (root canal treatment) visits the practice monthly. The practice has one treatment room and an instrument decontamination room.

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 Town Moor Dental Care Limited was the principal dentist.

During the inspection we spoke with two dental nurses, we spoke with the principal dentist by telephone after the focussed inspection. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday, Wednesday, Thursday and Friday 10am – 7pm

Tuesday 8am – 4pm

Our key findings were:

• Staff knew how to deal with emergencies. Systems were now in place to monitor emergency medicines and equipment.
• Improvements had been made to ensure the practice had systems to help them manage risk.
• Staff knew their responsibilities for safeguarding adults and children, safeguarding policies were now in place and staff were aware of reporting procedures.
• The practice’s recruitment procedures reflected current legislation.
• Staff appraisal and induction process were now embedded.
• Improvements had been made to lead and support the team.
• Audit processes had improved to ensure continuous improvement and innovation.

We carried out this announced inspection on 29 May 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.

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 not providing well-led care in accordance with the relevant regulations.

Background

Town Moor Dental Care is in Doncaster and provides private treatment to adults and children.

Entry into the practice is via a single step. Entry assistance is available if required for people who use wheelchairs and pushchairs. Car parking spaces are available at the practice.

The dental team includes the principal dentist and two dental nurses, one of whom is a trainee. A dentist who specialises in endodontics (root canal treatment) visits the practice on a monthly basis. The practice has one treatment room and an instrument decontamination room.

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 Town Moor Dental Care Limited was the principal dentist.

On the day of inspection we collected four CQC comment cards filled in by patients.

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

The practice is open:

Monday, Wednesday, Thursday and Friday 10am – 7pm

Tuesday 8am – 4pm

Our key findings were:

• The practice appeared clean and well maintained.
• The practice staff had infection control procedures which reflected published guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available but the management process was not effective.
• The practice had systems to help them manage risk but some improvements could be made to regularly review and embed the processes.
• Staff knew their responsibilities for safeguarding adults and children, improvements could be made to staff awareness of reporting procedures.
• The practice’s recruitment procedures did not reflect current legislation.
• 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 practice was providing preventive care and supporting patients to ensure better oral health.
• The appointment system met patients’ needs.
• Some improvements could be made to lead and support the team.
• The practice asked staff and patients for feedback about the services they provided but analysis of the results was not evident.
• The practice staff dealt with complaints positively and efficiently.
• The practice staff had suitable information governance arrangements.
• Continuous improvement and innovation was encouraged but some areas could be improved.

We identified regulations the provider was not meeting. They must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulations the provider was not meeting are at the end of this report.

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

• Review the practice’s safeguarding policies and ensure staff are aware of the correct reporting procedure.
• Review the process in place to ensure fire safety checks are documented and brought in line with relevant regulations.
• Review the practice’s system for recording, investigating and reviewing incidents or significant events with a view to preventing further occurrences and ensuring that improvements are made as a result.
• Review the security of the practice to ensure there are systems in place to protect patients, equipment and medicines should a staff member be absent from the reception area.