We carried out this announced inspection on 26 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 providing well-led care in accordance with the relevant regulations.

Background

Tracey Black’s Dental Surgery is in Headingley, Leeds and provides NHS and private treatment to adults and children.

There is access for people who use wheelchairs and those with pushchairs via a portable ramp. Car parking spaces are available near the practice and local transport facilities are nearby.

The dental team includes two dentists, two dental nurses (one of whom is a locum) and a receptionist. 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 50 CQC comment cards filled in by patients.

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

The practice is open:

Monday to Thursday 8:50am-5:30pm and Friday 8:50am-4:30pm.

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.
• The practice had systems to help them manage risk to patients and staff. A lone working risk assessment could be in place.
• The practice staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The provider had safe 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.
• The provider was providing preventive care and supporting patients to ensure better oral health.
• The appointment system met patients’ needs.
• The practice had effective leadership and culture of continuous improvement.
• 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 provider dealt with complaints positively and efficiently.

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

• Review the practice’s systems for assessing, monitoring and mitigating the various risks arising from the undertaking of the regulated activities. In particular undertaking risk assessments for staff who work alone.

We spoke with five patients who told us they were very satisfied with their experience of using the service. They said the staff were caring and easy to talk with. Comments made included, “I had a fear of dentist but I am now confident because they are fantastic.” “Excellent service they are very professional.”

People said the dentists explained the consultation procedure, which treatment would be most effective and reasons why they thought so. People felt they were treated with dignity and respect and said they had received consultations and treatment in private.

We saw treatment plans were detailed and included different options where these were appropriate and enabling patients to make an informed choice.

Staff told us they were well supported in their work and they enjoyed working in the practice. They told us communication was excellent and they were all able to contribute to how the service was provided.

We saw arrangements in place to deal with emergency situations including training for staff in medical emergencies and resuscitation.

The practice had effective procedures in place for the management of infection control. There was evidence to show that staff had received training to reduce the risk of infection.

Effective quality auditing procedures were undertaken and appropriate systems were in place for gathering, recording and evaluating information about the quality of the service provided.