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Inspection carried out on 17 December 2019

During a routine inspection

We carried out this announced inspection on 17 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 two specialist dental advisers.

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.


Westbourne Dental Practice is in Westbourne and provides private dental care and treatment for adults and children.

There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for people with disabilities, are available near the practice.

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

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. At the time of inspection there was no registered manager in post as required as a condition of registration. A registered manager is legally responsible for the delivery of services for which the practice is registered.

On the day of inspection, we collected 27 CQC comment cards filled in by patients and spoke with five other patients.

During the inspection we spoke with three dentists, one lead dental nurses, two dental nurses, two trainee dental nurses, three receptionists, one compliance and oversight manager and the interim practice manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

  • Monday to Thursday 8.30am to 5pm
  • Friday 8.30am to 3pm
  • Saturday 8.30am to 1.30pm

Our key findings were:

  • The practice appeared to be visibly clean and well-maintained.
  • 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 safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • The provider had staff recruitment procedures which reflected current legislation.
  • 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 infection control procedures which should be improved, for example the sequence of sterilisation procedures.
  • Improvements should be made to the management of prescription logs, the use of rubber dams and the removal of out of date materials.
  • Arrangements should be completed to register a new manager with the Care Quality Commission.

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

  • Implement an effective system for identifying, disposing and replenishing of out-of-date stock.

  • 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 the sequence of manual cleaning, automated cleaning and pouch sealing.

  • Take action to ensure dentists are aware of the guidelines issued by the British Endodontic Society for the use of rubber dam for root canal treatment.

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

  • Take action to ensure the regulated activities at Westbourne Dental Practice are managed by an individual who is registered as a manager.