CQC Fundamental Standards & Statutory Regulations Matrix
Comprehensive breakdown of the statutory fundamental standards and registration regulations governing dental providers in England. Clear mapping of direct prosecution offences, clinical requirements, and inspection evidence.
Fit and proper persons: Directors & Partners
Part 3: Fundamental Standards (2014)Ensures directors, partners, and governing officers are of good character, have necessary competence, are physically/mentally fit, and have not been responsible for serious misconduct/bankruptcy.
- Companies House director check & insolvency register check
- Enhanced DBS check for all partner dentists/directors
- Fit & Proper Person annual declaration adhering to Nolan principles of public life
Requirements relating to Registered Managers & Nominated Individuals
Part 3: Fundamental Standards (2014)Requires an appropriate, competent, skilled Registered Manager in day-to-day charge with necessary dental qualifications and suitability documentation (Schedule 3).
- GDC registration verification and dental practice management qualifications
- Continuous CPD in leadership, CQC regulations, and clinical governance
- Documented Nominated Individual supervision arrangements
Person-centred care
Part 3: Fundamental Standards (2014)Care and treatment must be appropriate, meet needs, and reflect patient preferences. Requires collaborative assessment, clear treatment plans, and reasonable adjustments.
- Personalised dental treatment plans (FP17DC / Private estimates) with agreed recall intervals
- Full explanation of risks, benefits, and alternatives (including option of doing nothing)
- Reasonable adjustments under Equality Act 2010 (wheelchair access, large print, translator support)
Dignity and respect
Part 3: Fundamental Standards (2014)Patients must be treated with dignity and respect at all times, ensuring privacy during clinical discussions/procedures and protection from discrimination.
- Clinical consultations and fee discussions held in closed surgery rooms with sound privacy
- Chaperone policy available for intimate/sensitive procedures
- Non-discriminatory care respecting all protected characteristics under Equality Act 2010
Need for consent
Part 3: Fundamental Standards (2014)Care and treatment may ONLY be provided with valid consent. Mentally incapacitated patients must be protected under Mental Capacity Act 2005. Under-16s assessed under Gillick competence.
- Montgomery-compliant informed consent discussing all material risks and aesthetic expectations
- Two-stage Mental Capacity Act 2005 assessment & best interests documentation for vulnerable adults
- Right to withhold or withdraw consent respected at any stage of treatment
Safe care and treatment
Part 3: Fundamental Standards (2014)Must prevent unsafe care, mitigate health & safety risks, control infection spread (HTM 01-05), ensure equipment safety, and manage medicines safely.
- HTM 01-05 compliant decontamination with daily autoclave logs and 6-monthly IPS audits
- Medical emergency kit & AED weekly checks complying with Resuscitation Council UK standards
- Safer sharps systems and compliance with MHRA / CAS Patient Safety Alerts
- Safe storage and dispensing of local anaesthetics, antibiotics, and prescription pads
Safeguarding service users from abuse and improper treatment
Part 3: Fundamental Standards (2014)Zero-tolerance to abuse, neglect, degrading treatment, or unlawful restraint. Requires robust safeguarding systems and immediate reporting.
- Lead Safeguarding Dentist appointed with Level 2/3 training (3-yearly)
- Clear protocol for recognizing non-accidental dental injuries (NADI) and child neglect
- Direct referral pathways to local Multi-Agency Safeguarding Hub (MASH)
Premises and equipment
Part 3: Fundamental Standards (2014)Premises and equipment must be clean, secure, suitable for purpose, properly maintained, and appropriately located with appropriate hygiene standards.
- Annual servicing and Pressure Systems Safety Regulations (PSSR 2000) written scheme for autoclaves/compressors
- Radiation safety critical examination and 3-yearly QA tests by Radiation Protection Adviser (RPA)
- Legionella risk assessment and monthly sentinel tap temperature monitoring (HTM 04-01)
Receiving and acting on complaints
Part 3: Fundamental Standards (2014)Must operate an accessible complaints system. All complaints must be investigated without delay with statutory response timescales.
- Written complaints policy displayed in waiting area and website
- Mandatory 3 working day acknowledgement and 10-20 day full investigation response
- Signposting to Parliamentary Ombudsman (NHS) and Dental Complaints Service (Private)
Good governance
Part 3: Fundamental Standards (2014)Must operate effective auditing and governance systems, maintain contemporaneous dental records, seek patient feedback, and continually improve quality.
- Clinical audit programme (HTM 01-05, Radiography IRMER, Record keeping, Antibiotic prescribing)
- Complete, contemporaneous, indelible dental records adhering to FGDP standards
- Regular practice governance meetings and Friends and Family Test (FFT) patient surveys
Staffing
Part 3: Fundamental Standards (2014)Must deploy sufficient numbers of suitably qualified, competent, and skilled staff who receive appropriate induction, supervision, appraisal, and mandatory training.
- Safe staffing levels with qualified dental nurses for four-handed dentistry
- Structured induction programme covering safety, IPC, medical emergencies, and local rules
- Annual staff appraisals and GDC Enhanced CPD portfolio maintenance
Fit and proper persons employed
Part 3: Fundamental Standards (2014)Robust recruitment checks (Schedule 3): ID, 2 written references, full employment history with gap analysis, Enhanced DBS, qualifications, and Hepatitis B immunity.
- Complete recruitment files with verified ID and references before start of employment
- Enhanced DBS check registered on DBS Update Service
- Hepatitis B antibody titer check (>100 mIU/mL) confirming immunity for clinical workers
Duty of candour
Part 3: Fundamental Standards (2014)Open and honest communication when things go wrong. For any notifiable safety incident (moderate harm, severe harm, or prolonged pain >28 days), must provide in-person explanation and written apology within 10 days.
- Significant Event Analysis protocol identifying notifiable safety incidents
- In-person notification with truthful account of facts and offer of reasonable support
- Formal written apology and copy of all correspondence securely archived
Requirement as to display of performance assessments (CQC Rating)
Part 3: Fundamental Standards (2014)Providers must conspicuously and legibly display their CQC performance assessment and rating at each practice premises and on their website.
- CQC inspection certificate/rating displayed in patient waiting room
- CQC digital widget and link to CQC inspection report on practice homepage
Statement of purpose
Part 4: Registration Regulations (2009)Must maintain a clear Statement of Purpose containing Schedule 3 details (aims, registered manager, locations, regulated activities). Must notify CQC within 28 days of any revision.
- Complete Parts 1-4 Statement of Purpose detailing primary dental care activities
- Annual review and written notification to CQC of any managerial or location change
Notice of absence & Notice of changes
Part 4: Registration Regulations (2009)Mandatory written notice to CQC 28 days before a continuous absence of 28+ days of the Registered Manager, and notice of return within 7 days. Notice of change in partners, directors, or provider status.
- Registered Manager absence notification procedure with designated acting manager
- Formal notification to CQC of any change in partnership or ownership structure
Notification of other incidents (CQC Reg 18)
Part 4: Registration Regulations (2009)Must notify CQC without delay of: serious injuries lasting >28 days, abuse allegations, incidents reported to police, service disruptions/utility outages >24 hours, fire alarm failures >24 hours.
- Immediate CQC notification for any dental patient hospital admission or permanent injury
- Notification if practice closes due to flood, fire, power failure, or compressor breakdown >24h
- Police incident reporting log for theft of prescription pads or physical threats
Fees & Written Cost Estimates
Part 4: Registration Regulations (2009)Must provide a written statement of terms, conditions, payment methods, and written cost estimates prior to the commencement of treatment.
- Itemised written treatment plan and fee estimate provided and signed before treatment commences
- Price list clearly displayed in waiting area and on website (NHS Band 1/2/3 & Private fee guide)
- Clear notice of payment terms and any deposit/cancellation policies