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Archived: Evesham Place Dental Practice

The provider of this service changed - see old profile


Inspection carried out on 20 October 2015

During a routine inspection

We carried out an announced comprehensive inspection on 20 October 2015 to ask the practice the following key questions: Are services safe, effective, caring, responsive and well-led?

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.


This report is about the service provided at Evesham Place Dental Practice by Andrew Browne, the provider. The practice provides NHS out of hours emergency dental treatment for all of South Warwickshire and NHS treatment for its own patients. Andrew Browne is also the clinical director and registered manager of Evesham Place Ltd which provides NHS and private dental treatment at the practice from Monday to Friday. We have produced a separate report about this although many elements of the two services are the same.

The out of hours service at Evesham Place is provided by members of the team from the main practice which is made up of four dentists, a regular locum dentist, three dental hygienists and eight dental nurses. The clinical team are supported by two full time practice managers, a senior receptionist and three receptionists. The dentists and dental nurses work on a rota system to provide cover each evening and at weekends and bank holidays.

The practice has five dental treatment rooms and a decontamination room for the cleaning, sterilising and packing of dental instruments. The reception area and main waiting room are on the ground floor and there is another smaller waiting room on the first floor.

Before the inspection we sent Care Quality Commission comment cards to the practice for patients to use to tell us about their experience of the practice. We collected 40 completed cards but only one of these appeared to have been filled in by a patient who had attended the practice to use the out of hours service. This described how the practice had seen them promptly and gave them treatment which resolved the pain they had been in. Patients of the main dental practice spoke highly of the practice team and were positive about their experience of being a patient there. The practice showed us the results of their 2015 NHS Friends and Family Test monthly surveys for July to September 2015. It was probable that some of these could have been from patients seen out of hours. These showed that from 71 responses 48 patients were ‘extremely likely’ to recommend the practice and 21 were ‘likely’ to do so. Of the remainder one was neutral about this. Only one said they were ‘unlikely’ to recommend the practice.

Our key findings were:

  • The practice had an established process for reporting and recording significant events and accidents to ensure they investigated these and took remedial action. The practice used significant events to make improvements and shared learning from these with the team.
  • The practice was visibly clean and had well organised systems to assess and manage infection prevention and control.

  • The practice had suitable safeguarding processes and staff understood their responsibilities for safeguarding adults and children.

  • The practice had recruitment policies and procedures and used these to help them check the staff they employed were suitable. The written policy did not fully reflect the requirements of legislation although the practice obtained the correct information.

  • When the practice saw patients from other practices they created dental care and treatment records as they would for patients of the main practice.

  • Staff received training appropriate to their roles and were supported in their continued professional development (CPD).

  • Patients were able to make emergency appointments at the practice through the NHS111 system which made an initial assessment and arranged for the on call dentist to speak with them if necessary. The dentist then arranged to see patients at the practice if they required further assessment and treatment.

  • The practice had systems including audits to assess, monitor and improve the quality and safety of the services provided.

  • The practice had systems to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients, staff and visitors.

There were areas where the provider could make improvements and should:

  • Establish a written policy regarding significant event reporting and recording to support their current practice.
  • Update the practice policy for safe use of sharps to include reference to the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 and the EU Directive on the safer use of sharps which came into force in 2013
  • Keep a record of the allocation of prescription pads in accordance with national guidance from NHS Protect.
  • Review their recruitment policy to fully reflect the requirements of Regulation 19(3) and Schedule 3 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014.
  • Record the reasons for taking X-rays and the grading of these every time one is taken.
  • Develop a structured process for recording staff induction to confirm individual staff knowledge and competence in the areas covered.