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Inspection carried out on 12 March 2019

During a routine inspection

We carried out this announced inspection on 12 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.


Bupa Dental Care Dereham is a well-established practice which provides both NHS and private treatment to approximately 8,000 patients. The dental team includes five dentists, one hygienist, eight nurses, three receptionists and a practice manager. The practice has five treatment rooms.

The practice opens on Mondays, Tuesdays and Thursdays from 8am to 7pm; on Wednesday from 8am to 6pm, and on Fridays from 8.15 to 5pm. The practice is also open one Saturday a month for hygienist appointments.

The practice has limited parking facilities, primarily for patients with disabilities, but there is car parking nearby. Wheelchair access is available and there are three ground floor treatment rooms.

The practice is owned by a company 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 the practice is the practice manager.

On the day of inspection, we collected 47 CQC comment cards filled in by patients and spoke with two other patients. We spoke with two dentists, three dental nurses, reception staff and the practice manager. One of the provider’s area compliance leads was also on site. We looked at practice policies and procedures and other records about how the service is managed.

Our key findings were:

  • Infection control procedures reflected published guidance.
  • Staff knew how to deal with emergencies, and appropriate medicines and life-saving equipment were available.
  • The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • The practice had thorough staff recruitment procedures.
  • Patients’ care and treatment was provided in line with current guidelines.
  • The practice offered evening and Saturday morning appointments.
  • The practice took complaints and concerns seriously and responded to them appropriately to improve the quality of care.
  • The practice had effective leadership and culture of continuous improvement.

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

  • Review the practice’s sharps procedures and ensure the practice follows the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

  • Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.

Inspection carried out on 25 November 2013

During a routine inspection

We spoke with the practice manager and four members of staff. We also spoke with four people who used the service and reviewed 11 sets of treatment records.

Treatment plans had been signed by the person, or by a parent or guardian, to indicate that they agreed with and gave consent to the proposed treatment. People we spoke with told us that staff explained their findings and proposed treatments to them before asking them to give consent to the plan. One person said "I've always known exactly what's going on."

The practice information pack included information on topics such as practice opening times and fees for private treatment. Each person we spoke with told us that they were satisfied with the care and treatment they received. One person explained that they had complex dental problems and that the dentist "...has worked very hard to treat my teeth."

There was a decontamination room for the sterilisation of dental instruments. Policies on infection control and the decontamination of dental instruments had been revised in August 2013. The practice also had procedures for the cleaning of treatment rooms between appointments and the manual cleaning of used dental instruments.

Staff were supported to undertake training and education, to help them to develop their skills and gain further qualifications. A system of staff appraisal was in place. Complaints were dealt with effectively and people were given information about the complaints process.