The Care Quality Commission
  • Dentist
  • Dentist

M I Bholah Dental Practice

64 Salters Road, Gosforth, Newcastle Upon Tyne, Tyne and Wear, NE3 1DX (0191) 285 7344

Provided and run by:
Dr. Mohammed Bholah

All Inspections

14 October 2022

During an inspection looking at part of the service

We undertook a follow up focused inspection of M I Bholah Dental Practice on 14 October 2022. This inspection was carried out to review in detail the actions taken by the registered provider to improve the quality of care and to confirm that the practice was now meeting legal requirements.

The inspection was led by a CQC inspector who was supported by a specialist dental adviser.

We undertook a focused inspection of M I Bholah Dental Practice on 7 July 2022 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We found the registered provider was not providing safe or well led care and was in breach of regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can read our report of that inspection by selecting the 'all reports' link for M I Bholah Dental Practice on our website www.cqc.org.uk.

As part of this inspection we asked:

• Is it safe?

• Is it well-led?

Our findings were:

Are services safe?

We found this practice was providing safe care in accordance with the relevant regulations.

The provider had made improvements in relation to the regulatory breach we found at our inspection on 7 July 2022.

Are services well-led?

We found this practice was providing well-led care in accordance with the relevant regulations.

The provider had made improvements in relation to the regulatory breach we found at our inspection on 7 July 2022.

Background

The provider has 2 practices and this report is about M I Bholah Dental Practice.

The practice is in Gosforth in Newcastle Upon Tyne and provides NHS dental care and treatment for adults and children.

There is level access to the practice for people who use wheelchairs and those with pushchairs. The practice is located near local transport routes and car parking spaces are available at the practice and in the surrounding streets.

The dental team includes a principal dentist and 2 dental nurse/receptionists. The practice has 1 treatment room.

During the inspection we spoke with the dentist and a dental nurse/receptionist. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday and Wednesday from 9:30am to 12:30pm

Tuesday from 9:30am to 12:30pm and from 1:30pm to 5pm

Thursday from 1:30pm to 5pm

Friday from 2pm to 5pm

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

  • Improve the practice's systems for assessing, monitoring and mitigating the various risks arising from the undertaking of the regulated activities. In particular, relating to the ongoing management of Legionella and ensuring all recommendations made in the fire safety risk assessment were actioned.
  • Take action to improve audits to ensure that, where appropriate, audits have documented learning points, action plans and the resulting improvements can be demonstrated.

7 July 2022

During an inspection looking at part of the service

We carried out this announced focused inspection on 7 July 2022 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 practice 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 a specialist dental adviser.

To get to the heart of patients’ experiences of care and treatment, we usually ask five key questions, however due to the ongoing COVID-19 pandemic and to reduce time spent on site, only the following three questions were asked:

• Is it safe?

• Is it effective?

• Is it well-led?

These questions form the framework for the areas we look at during the inspection.

Our findings were:

  • The practice had staff recruitment procedures which reflected current legislation.
  • Staff provided preventive care and supported patients to ensure better oral health.
  • The appointment system took account of patients’ needs.
  • Patients were asked for feedback about the services provided.
  • Staff told us they knew how to deal with medical emergencies. Most appropriate medicines and life-saving equipment were available. Improvements could be made to the monitoring protocol to ensure all equipment was available.
  • Safeguarding processes were in place; however not all staff knew the local protocols for escalating safeguarding concerns for vulnerable adults and children.
  • There was ineffective leadership and a lack of management oversight for the day-to-day running of the service.
  • Risks to staff and patients from undertaking of the regulated activities had not been suitably identified and mitigated.
  • There were ineffective systems to ensure facilities were safe and equipment was serviced and maintained according to manufacturers’ guidance.
  • The clinical staff provided patients’ care and treatment in line with current guidelines. Improvements were needed to ensure all important information was recorded consistently within the dental care records.
  • The practice appeared to be visibly clean and well-maintained. However, improvements were needed to the levels of cleanliness within some clinical areas and the storage arrangements for cleaning equipment.
  • The provider did not have infection control procedures which reflected published guidance.

Background

The provider has two practices and this report is about M I Bholah Dental Practice.

The practice is in Gosforth in Newcastle Upon Tyne and provides NHS dental care and treatment for adults and children.

There is level access to the practice for people who use wheelchairs and those with pushchairs. The practice is located near local transport routes and car parking spaces are available at the practice and in the surrounding streets.

The dental team includes one principal dentist and one dental nurse/receptionist. The practice has one treatment room.

During the inspection we spoke with the dentist, the dental nurse and a dental nurse/receptionist from the provider’s other practice. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday and Wednesday from 9:30am to 12:30pm

Tuesday from 9:30am to 12:30pm and from 1:30pm to 5pm

Thursday from 1:30pm to 5pm

Friday from 2pm to 5pm

We identified regulations the provider was not complying with. They must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulations the provider is not meeting are at the end of this report.

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

  • Implement audits for prescribing of antibiotic medicines taking into account the guidance provided by the College of General Dentistry.
  • Improve the practice protocols regarding auditing patient dental care records to check that necessary information is recorded.

13 September 2016

During a routine inspection

We carried out a follow- up inspection on 13 September 2016 at M I Bholah Dental Practice.

We had undertaken an announced comprehensive inspection of this service 30 March 2016 as part of our regulatory functions where breach of legal requirements were found.

After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach. This report only covers our findings in relation to those requirements.

We reviewed the practice against two of the five questions we ask about services: is the service safe and well-led?

We revisited M I Bholah Dental Practice as part of this review and checked whether they had followed their action plan and to confirm that they now met the legal requirements.

Our findings were:

Are services safe?

We found that this practice was providing safe 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.

Background

The practice is owned by Mr. M I Bholah. The practice is located on the ground floor of the building. There is a combined reception and waiting area, a washroom, a surgery and a decontamination room. The practice offers primary care dentistry under the NHS and private dental care.

The practice is open Monday to Friday 9.30am to 4.30pm.

There is a dentist and a dental nurse at the practice.

The principal dentist is registered with the Care Quality Commission (CQC) as an individual. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is run.

Our key findings were:

  • The system to check emergency medicines, the emergency oxygen and the automated external defibrillator was effective. All emergency medicines and equipment were in date and in line with guidance from the British National Formulary (BNF) and the Resuscitation Council UK.
  • An Infection Prevention Society (IPS) self- assessment audit had been completed and an action plan had been formulated and actioned.
  • Staff had completed training in infection control, the Mental Capacity Act (MCA) and safeguarding.
  • The practice had ceased to provide conscious sedation.

30 March 2016

During a routine inspection

We carried out an announced comprehensive inspection on 30 March 2016 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 not 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 not providing well-led care in accordance with the relevant regulations.

Background

The practice is owned by Mr. M I Bholah. The practice is located on the ground floor of the building. There is a combined reception and waiting area, a washroom, and surgery and decontamination room. The practice offers primary care dentistry under the NHS, including conscious sedation, and private dental care.

The practice is open Monday to Friday 9.30am to 4.30pm.

There is a dentist a dental nurse and a trainee dental nurse at the practice.

The principal dentist Mr M I Bholah is registered with the Care Quality Commission (CQC) as an individual. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is run.

We spoke with the dentist and both dental nurses.

On the day of inspection we received 18 CQC comment cards providing feedback. The patients who provided feedback were positive about the care and attention to treatment they received at the practice. They found the staff to be polite, friendly, helpful, efficient and professional. The practice was clean and tidy on the day of the inspection.

Our key findings were:

  • There was an effective complaints system.
  • There were sufficient numbers of qualified staff to meet the needs of patients.
  • Patient care and treatment was planned and delivered in line with evidence based guidelines and current regulations.
  • Patients received clear explanations about their proposed treatment, costs, benefits and risks, and were involved in making decisions about it.
  • Patients were treated with dignity and respect and confidentiality was maintained.
  • Patients could access routine treatment and urgent care when required.
  • The practice sought feedback from staff and patients about the services they provided in order to make improvements where needed.

We identified regulations that were not being met and the provider must:

  • Ensure the training, learning and development needs of staff members are reviewed at appropriate intervals and relevant training is undertaken when required.
  • Ensure all staff are aware of their responsibilities under the Mental Capacity Act (MCA) 2005 and the principles of the Gillick and Fraser competency guidance as it relates to their role.

​You can see full details of the regulations not being met at the end of this report.

There was an area where the provider could make improvements and should:

  • Review availability of equipment and medicines to manage medical emergencies giving due regard to guidelines issued by the Resuscitation Council (UK) standards for the dental team.
  • Review the practice’s protocols for the use of rubber dam for root canal treatment giving due regard to guidelines issued by the British Endodontic Society
  • Review the current decontamination processes and techniques and implement the required actions including the manual cleaning instruments under water before being sterilised, giving due regard to the guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.
  • Review the practice approach to supporting safe lone working arrangements for staff and implement a lone working policy.
  • Review the practice’s protocol for undertaking audits including dental care records and infection prevention and control at regular intervals to help improve the quality of service. The practice should also ensure all audits have documented learning points so the resulting improvements can be demonstrated.

19 September 2013

During a routine inspection

We saw people were given appropriate information about the service and the care and treatment they received. We spoke with three people who used the service who told us they understood the care and treatment choices available to them. One person said, "He (the dentist) talked me through everything. He is very good. He sits you down and explains what he's going to do before he starts. Then when he's working on your mouth he talks to you though things as he is doing it." Another person said, "Yes, it was all explained to me."

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. People told us they were happy with the care and treatments they had received. "It's champion. I had some dentures fitted about a fortnight ago. He made sure I was happy on the day. Asked me how it felt and did I need any changes made. It was fine, but he let me know I could come back if I had any problems."

Staff training was kept up to date so that staff could care for people safely and to an appropriate standard.

We found people were protected from the risk of infection because appropriate guidance had been followed and there was an effective system in place to monitor and assess the quality of the service.