We carried out this announced inspection on 7 November 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 and Healthwatch that we were inspecting the practice. They did not provide any information of concern.

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

Meanwood Dental Practice is in Leeds and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and pushchairs. Car parking spaces are available near the practice.

The dental team includes four dentists, five dental nurses (one of whom is a trainee) and a receptionist. Two of the dental nurses have managerial roles. The practice has three 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 41 CQC comment cards filled in by patients. This information gave us a positive view of the practice.

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

The practice is open:

Monday to Thursday from 9:00am to 5:30pm

Friday from 9:00am to 12:30pm

Our key findings were:

• The practice was clean and well maintained.
• The practice had infection control procedures which reflected published guidance.
• Improvements could be made to the processes for managing the risks associated with Legionella.
• 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. One member of staff did not have all the required recruitment documents present.
• 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.
• 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 and should:

• Review the practice’s process for following up sharps injuries.
• Review the availability of a valid legionella risk assessment and implement the required actions including the monitoring and recording of water temperatures, giving due regard to the guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.
• Review its responsibilities as regards to the Control of Substance Hazardous to Health (COSHH) Regulations 2002 and ensure all documentation is up to date.
• Review the practice's recruitment policy and procedures to ensure character references, proof of identification and a Disclosure and Barring Service (DBS) check are available for new staff.