We carried out this announced inspection on 5 March 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

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

Due to the nature of the premises wheelchair access is not possible. Wheelchair users are signposted to a local accessible practice. Car parking spaces are available near the practice.

The dental team includes one dentist, one dental nurse and a practice manager. The practice has one treatment room.

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 51 CQC comment cards filled in by patients.

During the inspection we spoke with the dentist, 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 from 8:30am to 5:15pm

Our key findings were:

• The practice appeared clean and well maintained.
• The provider 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 some systems to help them manage risk to patients and staff. Improvements could be made to the process for managing the risks associated with Legionella.
• The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• 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 and culture of continuous improvement.
• 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 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 Legionella risk assessment and implement the recommended actions, taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices.
• Review the process for ensuring equipment is maintained according to nationally recognised guidance.
• Review the practice's policy for the control of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken.

We spoke with four people who used the service and they said they were happy with the care and treatment that they received at the dental practice. People said the dentist had explained the care and treatment choices available to them. Everyone we spoke with said they did not have any concerns about the practice. One person said "I think it's a nice surgery, full of nice staff." Another said "I wouldn't take my kids anywhere else."

We spoke with all three staff members. One person said "I think this practice is excellent, clean, efficient and friendly". Another said "We speak to all our patients by their first names, most of our patients have been with us for years." Everyone we spoke with was very complimentary about the practice and would not consider going elsewhere. One member of staff said that even when patients move out of Leeds they still come back to the practice.