We carried out this announced inspection on 22 October 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 providing well-led care in accordance with the relevant regulations.

Background

Shelley and Pope Dental Practice is in Denton, Manchester and provides private treatment to adults and a small proportion of children.

There is a small step into the practice with level access for people who use wheelchairs and those with pushchairs at the rear of the practice. Car parking spaces are available near the practice.

The dental team includes two principal dentists and an associate dentist, five dental nurses, two dental hygiene therapists and two receptionists, one of whom is the reception manager. The team is supported by a practice manager. One of the principal dentists is registered with the General Dental Council as a specialist in prosthodontics (The replacement of teeth by crowns, bridges, dentures or dental implants). A visiting Consultant in oral and maxillofacial surgery provides additional support on an ad-hoc basis. The practice has four treatment rooms, a decontamination room and a library.

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. The registered manager at Shelley and Pope is the one of the principal dentists.

On the day of inspection, we collected 19 CQC comment cards filled in by patients.

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

The practice is open:

Monday and Wednesday 9am to 5pm

Tuesday and Thursday 9am to 7pm

Friday 8am to 3pm

Our key findings were:

• The practice appeared clean and well maintained.
• The provider 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 to patients and staff.
• The practice staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• 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.
• The provider was providing preventive care and supporting patients to ensure better oral health.
• The appointment system met patients’ needs.
• The practice had effective leadership and culture of continuous improvement.
• 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 provider dealt with complaints positively and efficiently.
• The provider had suitable information governance arrangements.

We identified an area of notable practice.

The practice offered and arranged free peer review training sessions three times a year to local dentists and dental staff interested in updating their skills in prosthodontics, endodontics, radiography and dental implants. The aim of this service was to promote learning between providers, develop insight about initiatives which would enhance the patient experience, promote good ideas and overall help to improve care to patients.

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

• Review the practice's systems for checking and monitoring equipment taking into account relevant guidance and ensure that equipment is well maintained. In particular: The second compressor.
• Review the practice’s systems for assessing, monitoring and mitigating the various risks arising from the undertaking of the regulated activities. In particular: The risks associated with the Control of Substances Hazardous to Health (COSHH).