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Inspection carried out on 29 October 2019

During a routine inspection

We carried out this announced inspection on 29 October 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.


Kirkby Dental Practice is in the market town of Kirkby in north Nottinghamshire and provides NHS and private dental treatment to adults and children.

The dental team includes four dentists, two dental hygienists, four trainee dental nurses who also have administrative and reception duties and a practice manager. The practice has four treatment rooms and an instrument decontamination room. All of the treatment rooms are located on the ground floor. There is level access into the practice which is of benefit for people with restricted mobility or who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice in pay and display car parks including spaces for blue badge holders and those with restricted mobility.

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 Kirkby Dental Practice is the principal dentist.

On the day of inspection, we collected 42 CQC comment cards filled in by patients these had provided positive feedback about the practice, the staff and the service being offered.

During the inspection we spoke with two dentists, one dental hygienist, three trainee dental nurses 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: 8.30am to 5.30pm.

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. Appropriate medicines and life-saving equipment were available.
  • Improvements could be made to the way NHS prescriptions were tracked to ensure their security.
  • 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 supporting patients to ensure better oral health.
  • The appointment system took account of patients’ needs.
  • Improvements to infection prevention and control procedures, particularly in respect of manual cleaning and tests on the ultrasonic cleaner.
  • The provider had effective leadership and culture of continuous improvement.
  • 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:

  • Improve the security of NHS prescription pads in the practice and ensure there are systems in place to track and monitor their use.

  • Improve the practice’s infection control procedures and protocols taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’ In particular, review the procedures for manual cleaning and ensure regular foil and protein tests are completed on the ultrasonic cleaner.