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Inspection carried out on To Be Confirmed

During a routine inspection

We carried out this unannounced inspection on 12 June 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 have any relevant information to share with us regarding this dental practice.

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.


Borrowash Dental Centre is located in premises in the village of Borrowash to the east of the city of Derby and provides mostly NHS dental treatment (95%) to patients of all ages.

There is ramped access for patients to the front door which makes access easy for people who use wheelchairs and pushchairs.

The dental team includes three dentists; three qualified dental nurses including two with a duel role as receptionists; one trainee dental nurse; and one full time receptionist. The practice has three treatment rooms, two of which are on the ground floor.

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 43 CQC comment cards filled in by patients and spoke with one other patient. This information gave us a positive view of the practice.

During the inspection we spoke with all staff in the practice. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open: Monday to Wednesday: 9 am to 5 pm; Thursday: 9 am to 12:30 pm and Friday: 8:30 am to 12:30 pm.

Our key findings were:

  • The practice was clean and well maintained.
  • The practice had infection control procedures which followed published guidance.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
  • The practice had systems to help them manage risks in the practice, particularly with regard to health and safety.
  • The practice had suitable safeguarding processes and staff had been trained and knew their responsibilities for safeguarding adults and children.
  • The practice 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 steps to protect their privacy and personal information.
  • The appointment system met patients’ needs. Patients said they could get an appointment that suited them.
  • 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 its responsibilities as regards the Control of Substances Hazardous to Health (COSHH) Regulations 2002 and ensure all documentation is up to date and staff understand how to minimise risks associated with the use and handling of these substances.   

  • Review the practice’s current Legionella risk assessment and implement the required actions taking into account guidelines issued by the Department of Health - Health Technical Memorandum  01-05: Decontamination in primary care dental practices and have regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.’

Inspection carried out on 1 November 2013

During a routine inspection

People told us they felt the practice delivered care and treatment in a way that met their needs and felt safe when they had treatment. One person told us �I�ve been with the practice for 6 years and have always received good treatment. I come here, as does my wife and two daughters. I can�t fault anything here�. We saw that equipment was in place for medical emergencies, such as oxygen and a defibrillator.

People told us they felt safe receiving treatment at the practice. Staff were aware of safeguarding issues and could tell us how they would report any concerns.

We saw that there were effective systems in place to reduce the risk and spread of infection. People also told us the practice was clean and that staff wore appropriate protective equipment.

The provider had an effective recruitment and selection procedures in place and carried out relevant checks on staff they employ.

The provider had clear systems in place to obtain feedback from all persons involved in the service as well as auditing their own service.