We carried out this announced inspection on 1 May 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 providing well-led care in accordance with the relevant regulations.

Background

Fitzwilliam Street Dental Care is in Rotherham, South Yorkshire and provides mainly NHS and a small amount of private treatment to adults and children.

Access to the practice is via steps from the street and a further set of steps into the building. The practice sits high above street level which makes access for people who use wheelchairs and those with pushchairs difficult; arrangements are in place to inform patients of the access constraints. Car parking spaces are available near the practice.

The dental team includes three dentists, (two of whom are principals), four dental nurses, (two of whom are trainees), one dental hygienist, one receptionist and a practice manager. The practice has three treatment rooms. The working practice currently extends over two floors, with an additional cellar and attic area. There is extensive refurbishment taking place on all four floors, internally and externally in line with building and fire regulations.

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 Fitzwilliam Dental Care is one of the principal dentists.

On the day of inspection, we collected 26 CQC comment cards filled in by patients. All comments reflected positively on the practice.

During the inspection we spoke with two dentists, one dental nurse 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 to Friday 9am to 6pm.

Our key findings were:

• The practice appeared clean and was maintained well amongst extensive refurbishment and building work.
• The provider had infection control procedures which reflected published guidance.
• Staff knew how to deal with emergencies. All medicines and life-saving equipment were available.
• The practice had systems to help them manage risk to patients and staff.
• The provider 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.
• Staff were providing preventive care and supporting patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• The provider had effective leadership.
• Overall the practice had a culture of continuous improvement with just one area that could be developed further.
• Staff felt involved and supported and worked well as a team.
• The provider asked staff and patients for feedback about the services they provided.
• The practice's responsibilities to take into account the needs of patients with disabilities and to comply with the requirements of the Equality Act 2010 were ongoing.
• The provider dealt with complaints positively and efficiently.
• The provider had suitable information governance arrangements.

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

• Review the practice’s protocols to ensure audits of radiography have documented learning points and the resulting improvements can be demonstrated.
• Review the practice's responsibilities to take into account the needs of patients with disabilities and to comply with the requirements of the Equality Act 2010.