We carried out this announced inspection on 23 May 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 provided information which we took 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

Callowbrook Dental Practice is in Rubery and provides NHS and private treatment to patients of all ages.

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

The dental team includes three dentists, two dental nurses, one dental hygienist and a practice manager. The practice manager and dental nurses also carried out reception duties. The practice has two treatment rooms.

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 26 CQC comment cards filled in by patients and spoke with three other patients. This information gave us a positive view of the practice.

During the inspection we spoke with one dentist, two dental nurses 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 8am – 6 pm

Tuesday 8am – 7pm

Wednesday 8am – 6pm

Thursday 8am – 5pm

Friday 8am – 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.
• 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 staff recruitment procedures but these required improvements.
• 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 appointment system met patients’ needs. However, some patients commented they were kept waiting beyond their scheduled appointment time.
• 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.

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

• Review the staff supervision protocols and ensure an effective process is established for the on-going appraisal of all staff
• Review the practice’s audit protocols to ensure audits of various aspects of the service, such as radiography and infection prevention and control are undertaken at regular intervals to help improve the quality of service. Practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.
• Review availability of an interpreter services for patients who do not speak English as a first language.
• Review the practice's recruitment policy and ensure that the recruitment arrangements are in line with Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Necessary employment checks should be in place for all staff and the required specified information in respect of persons employed by the practice should be held.

As part of our inspection we spoke with four people who were registered with the practice. We also spoke with the dentist, the practice manager and the dental nurse. We reviewed four dental records, looked at two staff files, policies and procedures and the quality assurance records.

People who used the practice told us that they were happy with the quality of treatment they received. They felt they were given enough information about their treatment options and were able to ask any questions that they wanted to.

People told us that the practice was clean and tidy and that they had no concerns about hygiene. The staff told us that regular infection control checks ensured that hygiene and cleanliness was maintained in clinical areas.

By looking through the staff records we were able to see that the dentists and staff were qualified and maintained their continuous professional development (CPD) as required by the General Dental Council (GDC).

Staff told us they were supported by their managers through regular staff meetings and supervisions. The staff said that this helped them make sure their training and development needs were identified and addressed.

We saw that there were regular audits and quality checks. We found evidence of actions being implemented from audits.