We carried out this announced inspection on 8 April 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 not providing well-led care in accordance with the relevant regulations.

Background

Victoria House Dental Practice is in Loughborough, a market town in the East Midlands. It provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. The practice does not have its own car park facility. Car parking spaces including those for blue badge holders, are available close to the practice in public car parks and on street.

The dental team includes six dentists, five dental nurses, six trainee dental nurses, one decontamination assistant, three dental hygienists, one dental hygiene therapist, six receptionists and two practice managers. The practice has 11 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 there was no registered manager in post as required as a condition of registration. A registered manager is legally responsible for the delivery of services for which the practice is registered. The practice manager had applied for the role in September 2018, but arrangements regarding this were yet to be finalised.

On the day of inspection, we collected 43 CQC comment cards filled in by patients.

During the inspection we spoke with six dentists, three dental nurses, two trainee dental nurses, the decontamination assistant, two receptionists, the practice manager, a compliance manager and head of clinical compliance. We looked at practice policies and procedures, patient feedback and other records about how the service is managed.

The practice is open: Monday to Friday from 8.30am to 5.30pm.

Our key findings were:

• The practice appeared clean, but some surgeries required action to be taken to ensure published guidance was followed.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
• The practice had systems to help them manage risk to patients and staff. We found that some issues were not addressed as promptly as they could be.
• The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children. Evidence of some staff training was sent to us after the day of inspection.
• The provider had thorough 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.
• Staff were providing preventive care and supporting patients to ensure better oral health.
• The appointment system took account of patients’ needs. There had been changes to the appointment system to increase access arrangements for patients.
• The practice was served by a dedicated practice manager who was new to their role; they demonstrated their effectiveness in leadership.
• Staff felt involved and supported by the practice manager, and worked well as a team.
• The provider responded to feedback left by patients about the services they provided.
• The provider dealt with complaints positively and efficiently.
• The provider had suitable information governance arrangements.

We identified regulations the provider was not complying with. They must:

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

Full details of the regulation 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 procedures for obtaining and recording patient consent to care and treatment to ensure they are in compliance with legislation, take into account relevant guidance, and staff follow them.