We carried out this announced inspection on 19 September 2017 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 that we were inspecting the practice. They did not provide any information for us to take into account.

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

Bordesley Village Dental Practice is in Birmingham and provides NHS treatment to patients of all ages.

There is level access for people who use wheelchairs and pushchairs. Car parking spaces, including two for patients with disabled badges, are available near the practice.

The dental team includes three dentists, four dental nurses (all of whom are trainees) and two practice managers (one of whom is a qualified dental nurse). The practice has three treatment rooms. An independent advisor visits the practice on a fortnightly basis to assits with its management.

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.

On the day of inspection we collected 34 CQC comment cards filled in by patients and spoke with one other patient. This information gave us a positive view of the practice.

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

The practice is open between 9am and 5:30pm from Monday to Friday. It also opens on Saturdays between 9am and 1pm.

Our key findings were:

• The practice was 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 with the exception of few items.
• 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 recruitment procedures but these were not thorough.
• The clinical staff provided patients’ care and treatment in line with current guidelines; however, some of the staff required further training in patient consent and the delivery of oral health promotion.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• The appointment system met 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 recruitment procedures to ensure that appropriate background checks are completed prior to new staff commencing employment at the practice.
• Review the practice’s system for documentation of actions taken, and learning shared, in response to incidents with a view to preventing further occurrences and ensuring that improvements are made as a result.
• Review availability of equipment to manage medical emergencies taking into account guidelines issued by the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.
• Review the practice's protocols for completion of dental care records taking into account guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.
• Review the practice’s protocols and procedures for promoting the maintenance of good oral health taking into account guidelines issued by the Department of Health publication ‘Delivering better oral health: an evidence-based toolkit for prevention’.
• Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.

During our visit, we spoke with the provider, practice manager and one dental nurse. We observed three consultations with patients using the service on the day of our visit. Following our visit, we spoke with three people who had recently used the service.

All three people we spoke with told us that they had used the practice for many years and were very happy with the service provided. One person told us, “I live a good few miles away but still come here because the dentist is so good’’. Another person told us, “It is such a good practice, staff are great I have had nothing but excellent treatment’’.

During the consultations, we observed we saw that treatment was explained to people and all three people spoken with confirmed that their treatment was always explained to them so they knew in advance their treatment plans. This meant people were given the information they needed to be able to make an informed decision about their treatment.

The provider had effective infection control procedures. This meant the risk of infection for people using the service was minimised.

Staff received a range of training so that they had up to date knowledge and skills in order to treat people safely when they attended the practice.

There were systems in place to monitor how the practice was run to ensure people received a quality service. This meant people using the service were asked their views about the service so the provider could use the information to improve.