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Inspection carried out on 24 September 2019

During a routine inspection

We carried out this announced inspection on 24 September 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 this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

We found this practice was providing effective care in accordance with the relevant regulations.

Are services caring?

We found this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found this practice was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found this practice was providing well-led care in accordance with the relevant regulations.


Tetbury Dental Practice is located on the first floor of Tetbury hospital on the edge of Tetbury and provides NHS and private dental treatment to adults and children.

There is level access into the building for people who use wheelchairs and those with pushchairs and a lift to the first floor. Car parking spaces, including some for blue badge holders, are available in the hospital car park.

The dental team includes six dentists, six dental nurses and one trainee dental nurse, two dental hygienists, a practice manager and five receptionists. The practice has six treatment rooms.

The practice is owned by a partnership and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run. The registered manager at Tetbury Dental Practice is the practice manager.

On the day of inspection, we collected 40 CQC comment cards filled in by patients and spoke with two other patients.

During the inspection we spoke with six dentists, six dental nurses, two receptionists 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 08.40am – 1.00pm and 2.00pm – 5.00pm
  • Closed at weekends

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 provider had systems to help them manage risk to patients and staff.
  • The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • The provider 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 care to protect their privacy and personal information.
  • Staff provided preventive care and supported patients to ensure better oral health.
  • The appointment system took account of patients’ needs.
  • The provider had effective leadership and a culture of continuous improvement. Improvements could be made to the leadership arrangements when the practice manager is not at the practice.
  • 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:

  • Implement an effective system for recording, investigating and reviewing accidents with a view to preventing further occurrences and ensuring that improvements are made as a result.
  • Take action to ensure all staff have received training to manage medical emergencies taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.
  • Implement a system to ensure patient referrals to other dental or health care professionals are centrally monitored to ensure they are received in a timely manner and not lost.
  • Improve the practice arrangements for ensuring good governance and leadership are sustained in the longer term.

Inspection carried out on 14 March 2012

During a routine inspection

People waiting for treatment told us how they were �always treated well and with respect� and how dentists �respect them and are always pleasant�. They spoke about the �understanding and sympathetic� reception staff and how they found the telephone reminders about their appointments to be useful.

We also reviewed the NHS Choices website and found that this was positive about the service.

Staff were enthusiastic about their roles, and told us they felt supported. They appreciated the training opportunities available to them. Staff had an understanding of the safeguarding arrangements for adults and children.