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

Background

Limes Dental Centre is in Worsley, Manchester and provides NHS and private treatment for adults and children.

Portable ramps are available for people who use wheelchairs and those with pushchairs. On street parking is available near the practice.

The team is comprised of the practice owner who is also the dentist and a part time dental therapist. The owner’s partner provides management, business, administrative and reception support. At the time of the inspection, there were no dental nurses employed by the practice. They employ agency dental nurses. There are 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 one CQC comment card filled in by patients and saw other sources of patient feedback.

During the inspection we spoke with the practice owner, their partner and an agency dental nurse. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday 9am to 1pm and 2pm to 5.30pm

Tuesday 9am to 12.30pm

Wednesday and Thursday 9am to 1pm and 2pm to 6pm

Friday 9am to 1pm.

Our key findings were:

• The practice appeared clean and well maintained.
• The provider had infection control procedures which reflected published guidance.
• Emergency medicines and life-saving equipment were not in line with guidance. Arrangements for life support training required improvement.
• The systems to help them identify and manage risks to patients and staff required improvement.
• The practice safeguarding processes required updating and making available to staff.
• The provider did not have thorough recruitment procedures in relation to employed or agency staff.
• 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 asked 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 regulations the provider was not complying with. They must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulations the provider is not meeting are at the end of this report.