Ombersley Family Dental Practice

We carried out this announced comprehensive inspection on 27 January 2023 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 advisor.

To get to the heart of patients’ experiences of care and treatment, we always ask the following 5 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:

• The dental clinic appeared clean and well-maintained.
• The practice had infection control procedures which reflected published guidance.
• Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
• The practice’s systems to manage risks for patients, staff, equipment and the premises were not effective or embedded.
• Policies and procedures which explained the steps staff within the practice must take to safeguard children and vulnerable adults were not robust or effective.
• The practice’s staff recruitment policy and procedures did not fully reflect current legislation.
• Clinical staff did not always evidence that they provided patients’ care and treatment in line with current guidelines. In particular, rubber dam was not always used in line with guidance.
• Patients were treated with dignity and respect. Staff took care to protect patients’ privacy and personal information.
• Staff provided preventive care and supported patients to ensure better oral health.
• The appointment system worked efficiently to respond to patients’ needs.
• The frequency of appointments was agreed between the dentist and the patient, giving due regard to National Institute of Health and Care Excellence (NICE) guidelines.
• Staff felt involved, supported and worked as a team.
• An evidence of a culture of continuous improvement was not observed. Not all required audits were carried out.
• The provider asked staff and patients for feedback about the services provided.
• Complaints were dealt with positively and efficiently.
• The practice had information governance arrangements.

Background

Ombersley Family Dental Practice is in Worcestershire and provides private dental care and treatment for adults and children.

There is step free access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for disabled people, are available outside the practice. The practice has made reasonable adjustments to support patients with access requirements.

The dental team includes 2 dentists, 8 dental nurses, and the business consultant. The practice has 3 treatment rooms.

During the inspection we spoke with 1 dentist, 4 dental nurses, and the business consultant. We looked at practice policies, procedures and other records to assess how the service is managed.

The practice is open:

Monday from 8.30am to 6.00pm
Tuesday from 8.45am to 4.45pm
Wednesday from 8.45am to 4.00pm
Thursday from 7.30am to 2.15pm
Friday from 7.00am to 12.30pm

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

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulation the provider was not meeting are at the end of this report.

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

• Improve the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment. In particular, ensure staff use rectangular collimators when taking X-rays.
• 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.