You are here

Comberton Dental Surgery Limited


Inspection carried out on 11 April 2018

During a routine inspection

We carried out this announced inspection on 11 April 2018 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.


Comberton Dental Surgery Limited is in Kidderminster and provides predominantly private treatment with a small NHS provision to patients of all ages.

There is ramped access for people who use wheelchairs and those with pushchairs. The practice has ample car parking available for patients at the rear of the building.

The dental team includes three dentists, seven dental nurses who also work in reception, a decontamination nurse, three dental hygienists, one receptionist, an assistant practice manager and a practice manager. The practice has three treatment rooms.

The practice is owned by a company 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 Comberton Dental Surgery Limited was the principal dentist.

On the day of inspection we collected 92 CQC comment cards filled in by patients and spoke with two other patients.

During the inspection we spoke with three dentists, three dental nurses, a decontamination nurse, two receptionists, the assistant practice manager 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: from 8.30am to 1.30pm and from 2.30pm to 6pm

Tuesday: from 8.30am to 1pm and from 2pm to 6pm

Wednesday: from 8.30am to 1pm and from 2pm to 5pm

Thursday: from 8.30am to 1pm and from 2pm to 5.30pm

Friday: from 8.30am to 1pm

Our key findings were:

  • Effective leadership was provided by the principal dentist and an empowered practice management team.
  • Staff we spoke with felt well supported by the principal dentist and practice management team and were committed to providing a quality service to their patients by ensuring their patients were their main priority.
  • The practice appeared clean and well maintained.
  • The practice had infection control procedures which reflected published guidance.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were mostly available, with the exception of a child reservoir bag which was immediately ordered.
  • The practice had systems to help them manage risk. There was a process in place for the reporting and shared learning when significant events occurred in the practice.
  • The practice staff had embedded safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
  • The practice had thorough staff recruitment procedures.
  • The clinical staff provided patients’ care and treatment in line with current guidelines. New updates were shared with staff at practice meetings.
  • Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • The practice was providing preventive care and supporting patients to ensure better oral health.
  • The appointment system met patients’ needs. Patients could access routine treatment and urgent and emergency care when required.
  • The practice had effective leadership and culture of continuous improvement.
  • The practice asked staff and patients for feedback about the services they provided. Results of these audits were analysed and action plans implemented.
  • The practice staff dealt with complaints positively and efficiently.
  • The practice staff had suitable information governance arrangements.

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

  • Review its responsibilities to the needs of people with a disability, including those with hearing difficulties and the requirements of the Equality Act 2010.

Inspection carried out on 25 July 2013

During an inspection looking at part of the service

We found that the provider had made improvements to its medicines management system since our last inspection in April 2013. People were protected from risks associated with the unsafe use of medicines because those medicines were managed appropriately.

Inspection carried out on 24 April 2013

During a routine inspection

We spoke with five people who had recently used the practice. We also spoke with the practice manager, the deputy manager and three dental nurses.

People who used the practice told us that they were happy with the quality of treatment they had received. One person told us: �I�m happy with the service. Nothing seems like a chore for them.� Another person said: �I�d definitely recommend them.�

People felt they were given enough information about their treatment options and the relevant fees, and were able to ask all the questions they wanted to.

People were protected from the risk of abuse because staff had been trained how to recognise signs of abuse and knew how to report concerns.

We found that people received care and treatment in a clean and hygienic environment. People we spoke with had no concerns about the cleanliness of the practice.

We found that people were not fully protected against risks associated with the use and management of medicines.

We found that staff were supported to deliver care and treatment safely and to an appropriate standard.

We looked at records which showed that the provider was regularly monitoring the quality of its service.