• Dentist
  • Dentist

Pomeroy & Rust Dental Practice

28 Sheep Street, Bicester, Oxfordshire, OX26 6LG (01869) 255558

Provided and run by:
V2Ray Ltd

Important: The provider of this service changed. See old profile

All Inspections

15 January 2024

During an inspection looking at part of the service

We undertook a follow up focused inspection of Pomeroy & Rust Dental Practice on 15 January 2024.

This inspection was carried out to review 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 remotely supported by a specialist dental advisor.

We had previously undertaken a comprehensive inspection of Pomeroy & Rust Dental Practice on 3 August 2023 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 well-led care and was in breach of regulation 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 Pomeroy & Rust Dental Practice on our website www.cqc.org.uk.

1 or more of the 5 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 area(s) where improvement was required.

As part of this inspection, we asked:

• Is it well-led?

Our findings were:

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 3 August 2023.

Background

Pomeroy and Rust is in Bicester and provides private dental care and treatment for adults and children.

The practice is based on the first floor which is a barrier to wheelchair users and people with limited mobility. Patients are advised of this when they contact the practice.

The dental team includes 2 dentists, 2 dental nurses, 1 dental hygienist and a head receptionist who supports the provider with administration duties.

The practice has 4 treatment rooms of which 3 are in use.

During the inspection we spoke with the head receptionist.

We looked at practice policies, procedures and other records to assess how the service is managed.

The practice is open:

• 9.00am to 5.30pm Monday to Thursday

• 9.00am to 7.00pm Friday

• 9.00am to 3.00pm Saturday


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

  • Take action to implement outstanding recommendations in the practice's fire safety risk assessment to ensure ongoing fire safety management is effective.

3 August 2023

During an inspection looking at part of the service

We undertook a follow up focused inspection of Pomeroy & Rust Dental Practice on 3 August 2023.

This inspection was carried out to review 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 advisor.

We had previously undertaken a comprehensive inspection of Pomeroy & Rust Dental Practice on 31 March 2023 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 well-led care and was in breach of regulation 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 Pomeroy & Rust Dental Practice on our website www.cqc.org.uk.

When 1 or more of the 5 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.

As part of this inspection, we asked:

• Is it well-led?

Our findings were:

Are services well-led?

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

The provider had made significant improvements, however a number of the improvements required remained outstanding which meant they had not fully responded to the regulatory breach we found at our inspection on 31 March 2023.

Background

Pomeroy and Rust is in Bicester and provides private dental care and treatment for adults and children.

The practice is based on the first floor which is a barrier to wheelchair users and people with limited mobility. Patients are advised of this when they contact the practice.

The dental team includes 2 dentists, 2 dental nurses, 1 dental hygienist and a head receptionist who supported the provider with administration duties.

The practice has 4 treatment rooms of which 3 are in use.

During the inspection we spoke with 1 dentist and the head receptionist.

We looked at practice policies, procedures and other records to assess how the service is managed.

The practice is open:

• Monday 9.00am to 5.30pm

• Tuesday 9.00am to 5.30pm

• Wednesday 8.00am to 5.30pm

• Thursday 9.00am to 5.30pm

• Friday 9.00am to 7.00pm

• Saturday 9.00am to 3.00pm

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:

  • Take action to ensure that all clinical staff have adequate immunity for vaccine preventable infectious diseases.

31 March 2023

During a routine inspection

We carried out this announced comprehensive inspection on 31 March 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 provider’s infection control procedures were not operated effectively.
  • The appointment system worked efficiently to respond to patients’ needs.
  • The provider did not operate effective systems to help them manage risk to patients and staff.
  • Staff knew how to deal with medical emergencies, but improvement was needed to ensure emergency equipment was appropriate.
  • The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • The provider’s staff recruitment procedures were not operated effectively.
  • Staff provided preventive care and supported patients to ensure better oral health.
  • Staff training was not monitored effectively.
  • The provider did not have effective leadership and a culture of continuous improvement.
  • Staff and patients were asked for feedback about the services provided.
  • Complaints were dealt with positively and efficiently.

Background

Pomeroy and Rust is in Bicester and provides private dental care and treatment for adults and children.

The practice is based on the first floor which is a barrier to wheelchair users and people with limited mobility. Patients are advised of this when they contact the practice.

The dental team includes 3 dentists, 3 dental nurses, of which one is a receptionist until their immunity to hepatitis is known, 1 dental hygienist and a head receptionist who supported the provider with administration duties.

The practice has 4 treatment rooms of which 3 are in use.

During the inspection we spoke with 1 dentist, 1 dental nurse, 1 dental hygienist , 1 receptionist and a head receptionist.

We looked at practice policies, procedures and other records to assess how the service is managed.

The practice is open:

  • Monday 9.00am to 5.30pm
  • Tuesday 9.00am to 5.30pm
  • Wednesday 8.00am to 5.30pm
  • Thursday 9.00am to 5.30pm
  • Friday 9.00am to 7.00pm
  • Saturday 9.00am to 3.00pm

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:

  • Implement audits for prescribing of antibiotic medicines taking into account the guidance provided by the College of General Dentistry.
  • Take action to ensure an automated external defibrillator (AED) is available immediately to manage medical emergencies, taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council, and undertake a risk assessment if a decision is made not to have an AED on site.
  • Implement an effective system for receiving and responding to patient safety alerts, recalls and rapid response reports issued by the Medicines and Healthcare products Regulatory Agency, the Central Alerting System and other relevant bodies, such as Public Health England.
  • Take action to ensure that all clinical staff have adequate immunity for vaccine preventable infectious diseases.

The provider accepted the shortfalls that we raised and took immediate action the day of our inspection to begin to address these.

Where evidence is sent that shows the relevant issues have been acted on, we have stated this in our report, but we cannot say that the practice is compliant for that key question as this would not be an accurate reflection of what was found on the day of our inspection.