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Inspection carried out on 10 December 2019

During a routine inspection

We carried out this announced inspection on 10 December 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 Care Quality Commission, (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.


Bore Street Dental Practice is in Lichfield, Staffordshire and provides NHS and private dental care and treatment for adults and children.

There is wheelchair and pushchair access to the practice. Car parking spaces, including dedicated parking for people with disabilities, are available in pay and display car parks near to the practice.

The dental team includes ten dentists, 16 dental nurses, two dental hygienists, five receptionists, one book keeper and one practice manager. The practice has nine treatment rooms in the main building and one treatment room in the garden surgery.

The practice is owned by a company and as a condition of registration must have a person registered with the CQC 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 Bore Street Dental Practice is one of the two principal dentists.

On the day of inspection, we collected 36 CQC comment cards filled in by patients.

During the inspection we spoke with four dentists, four 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 from 8.30am to 5.30pm.

Our key findings were:

  • The practice appeared to be visibly 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. We found that the practice had not ensured that X-ray equipment had been serviced annually, this was immediately scheduled following our visit.
  • The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children. Whilst all staff had received regular safeguarding training they had not all received training to level two. This had been scheduled for January 2020.
  • The provider had staff recruitment procedures which reflected current legislation. However, we found that two references were not always received for all staff.
  • 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. They routinely referred patients to their dental hygienists through a clear care pathway.
  • The appointment system took account of patients’ needs.
  • The provider had effective leadership and a culture of continuous improvement.
  • Staff felt involved and supported and worked 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 information governance arrangements.

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

  • Improve the practice's recruitment policy and procedures to ensure accurate, complete and detailed records are maintained for all staff.

  • Take action to ensure that all the staff have received training, to an appropriate level, in the safeguarding of children and vulnerable adults.
  • Improve the practice's systems for checking and monitoring equipment taking into account relevant guidance and ensure that all equipment is well maintained. In particular, ensuring X-ray equipment is serviced in accordance with manufacturers guidance.