The Care Quality Commission
  • Dentist
  • Dentist

Old Grammar School Dental Surgery

1 Ramsey Road, St Ives, Cambridgeshire, PE27 5BZ (01480) 466466

Provided and run by:
Dr Tim Rodgers

All Inspections

During an assessment under our new approach

We carried out this short notice announced inspection on 12 May 2025. The inspection was focused in response to information of concern we received. We covered the key questions safe, effective and well-led.

We found the practice had met regulations.

The practice had effective systems to identify and manage risks.

Infection control procedures in place were effective.

Recruitment procedures broadly reflected current legislation and there was effective leadership and a culture of continuous improvement.

Patients’ care and treatment was provided in line with current guidance.

Patients were treated with dignity and respect and at the time of our inspection, could access care, support and treatment when required.

Old Grammar School is in St Ives, Cambridgeshire and provides NHS and private dental care and treatment for adults and children.

There was step-free access to the practice and car parking spaces available, including dedicated parking for disabled people, near the practice.

The practice had 3 treatment rooms with 1 treatment room on the ground floor and a wheelchair accessible toilet.At the time of our inspection, there was a total of 10 staff, of which there were 2 principal dentists, 2 associate dentists, 2 qualified dental nurses, 1 trainee dental nurse, 2 receptionists and the practice manager. We spoke to staff present during our inspection, including the 2 principal dentists, 1 receptionist and the practice manager.

18 May 2021

During an inspection looking at part of the service

We undertook a follow up focused inspection of The Old Grammar School Dental Surgery on 18 May 2021. 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 comprehensive inspection of The Old Grammar School Dental Surgery on 20 August 2019 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 The Old Grammar School Dental Surgery on our website www.cqc.org.uk.

As part of this inspection we asked:

• Is it safe?

• Is it well-led?

When one or more of the five questions are not met, we require the service to make improvements and send us an action plan. We then inspect again after a reasonable interval, focusing on the areas where improvement was required.

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 breaches we found at our inspection on 20 August 2019.

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 breaches we found at our inspection on 20 August 2019.

Background

The Old Grammar School Dental Practice is a well-established service based in St Ives, Cambridgeshire that offers both private and NHS general dental treatment to approximately 5,000 patients.

The dental team consists of three dentists, a practice manager, four dental nurses and a receptionist. There are three treatment rooms. The practice opens on Mondays to Fridays, from 8am to 5pm. There is portable ramp access for wheelchair users and parking right in front of the building.

The practice is owned by an individual who is the one of dentists there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.

During the inspection we spoke with two dentists, one dental nurse and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.

Our key findings were:

  • Systems and processes were in place to ensure incidents, accidents and near misses were investigated.
  • X-ray equipment was appropriately maintained and serviced.
  • Dental care records reflected standards as laid out by the Faculty of General Dental Practice (FGDP).
  • Infection prevention and control processes reflected nationally recognised guidance.
  • There was a system in place to monitor the use and security of prescription pads.
  • There were systems in place to assess and monitor the quality and safety of the service.

20 August 2019

During a routine inspection

We carried out this announced inspection on 20 August 2019 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 this practice was not providing safe care in accordance with the relevant regulations.

Are services effective?

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

Are services caring?

We found this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

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

Are services well-led?

We found this practice was not providing well-led care in accordance with the relevant regulations.

Background

The Old Grammar School Dental Practice is a well-established service based in St Ives, Cambridgeshire that offers both private and NHS general dental treatment to approximately 5,000 patients.

The dental team consists of three dentists, a practice manager, five dental nurses and reception staff. There are three treatment rooms. The practice opens on Mondays to Fridays, from 8am to 5pm. There is portable ramp access for wheelchair users and parking right in front of the building.

The practice is owned by an individual who is the one of dentists there. He has legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.

On the day of inspection, we collected 40 CQC comment cards filled in by patients and spoke with another two patients.

During the inspection we spoke with three dentists, two nurses and reception staff. We looked at practice policies and procedures and other records about how the service is managed.

Our key findings were:

  • Staff treated patients with dignity and respect, and we received many positive comments from patients about the caring and empathetic nature of the dentists.

  • The practice was small and friendly, something which both patients and staff appreciated.

  • The practice appeared clean and well maintained.
  • The appointment system met patients’ needs and patients could get an emergency appointment easily.

  • There was no effective system for reviewing incidents or significant events with a view to preventing further occurrences and ensuring that improvements were made as a result.

  • Medicines were not managed effectively.

  • There was no system in place to ensure that X-ray equipment was properly serviced.
  • Patients’ dental care records did not reflect standards set by the Faculty of General Dental Practice regarding clinical examinations and record keeping.
  • Some of the practice’s infection control procedures did not comply with national guidance.

  • There were no effective systems to assess and monitor the quality of service provision.

We identified regulations the provider was not meeting. 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 was not meeting are at the end of this report.

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

  • Review the practice’s protocols for the use of dental dams for root canal treatment taking into account guidelines issued by the British Endodontic Society.

  • Review the practice’s protocols for recording in the patients’ dental care records or elsewhere the reason for taking X-rays, a report on the findings and the quality of the image in compliance with Ionising Radiation (Medical Exposure) Regulations 2017.

8 May 2013

During a routine inspection

We checked the provider's website and spoke to three staff and four people who use the service. People who use the service confirmed that the provider's web information was accurate and clearly described what people could expect if they chose to use this practice.

All four people told us that the service was, 'Excellent'. Two people had been registered with the service for a number of years, while the other two were relatively new to the practice, but all confirmed that they were treated with full respect, as individuals and, as one of them explained that, 'All staff are very professional and kind.'

All individual records were accurate, securely stored and kept up to date. A dentist told us that they reminded people by phone a few days before their booked appointments. Although the majority of people treated were local and staff knew them from the community, the practice also treated some people who had moved away, even some from abroad.

All staff completed training on protection of children and vulnerable adults and their regular training as required by the General Dental Council. Staff were appraised through a yearly programme by the practice manager and owner.

We checked the records of infection control practices and procedures and all were appropriate.

We checked 13 feedback forms collected by the provider, all of which were very positive.