Damira Bicester

We carried out this announced inspection on 9th 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 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.

Background

Damira Dental Studios is in Bicester and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces, including spaces for blue badge holders, are available near the practice.

The dental team includes two dentists, one dental nurse, one trainee dental nurse, one dental hygienist and one receptionist. 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.

At the time of inspection there was no registered manager in post as required as a condition of registration. A registered manager is legally responsible for the delivery of services for which the practice is registered. We were told the practice manager was going through the registration process to become the registered manager.

On the day of inspection, we collected 18 CQC comment cards filled in by patients and obtained the views of 11 other patients.

During the inspection we spoke with one dentist, one dental nurse, one receptionist. The area manager and head of area managers attended the inspection in place of the practice manager who was on leave.

We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

• Monday 8.30 -17.30
• Tuesday 8.30 -17.30
• Wednesday 8.30 -17.30
• Thursday 8.30 -17.30
• Friday 8.30 -17.30

Our key findings were:

• The practice appeared clean and well maintained.
• The provider had infection control procedures which reflected published guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
• The provider had systems to help them manage risk to patients and staff.
• The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The provider had thorough staff recruitment procedures.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• Staff provided preventive care and supporting patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• The provider had effective leadership and culture of continuous improvement.
• Staff felt involved and supported and worked well as a team.
• The provider asked staff and patients for feedback about the services they provided.
• The provider dealt with complaints positively and efficiently.
• The provider had suitable information governance arrangements.

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

• Review the practice's and implement any recommended actions, taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05. In particular, water temperature monitoring.
• Review the availability of equipment taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.
• Review the practice’s system for recording, investigating and reviewing incidents or significant events with a view to preventing further occurrences and ensuring that improvements are made as a result.
• Review the practice's procedures to ensure patient referrals to other dental or health care professionals are received in a timely manner.
• Review the provider's registration conditions to ensure the regulated activities at Damira Bicester are managed by an individual who is registered as a manager .