The Care Quality Commission
  • Dentist
  • Dentist

No. 1 Nursery Road Dental Practice

1 Nursery Road, Edgbaston, Birmingham, West Midlands, B15 3JX (0121) 427 7727

Provided and run by:
Drs S & N Waddell

Important: This service was previously registered at a different address - see old profile

All Inspections

During an assessment under our new approach

We had previously undertaken a comprehensive inspection under our previous methodology of No 1 Nursery Road Dental Practice on 26 March 2024 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. We undertook a follow up off site assessment on 2 September 2024. This assessment 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. We found the practice had met regulations. The practice had systems to manage risks and there was effective leadership and a culture of continuous improvement. The practice is in Birmingham and provides private dental care and treatment for adults and children. At the time of our assessment, the dental team included 3 dentists and 1 dental nurse. The practice had 2 treatment rooms. During the assessment we spoke with 1 dentist.

26 March 2024

During a routine inspection

We carried out this announced comprehensive inspection on 26 March 2024 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. Checks of medical emergency equipment and medicines were not effective and did not take into account the guidelines issued by the Resuscitation Council (UK).
  • Systems to manage risks for patients, staff, equipment and the premises needed improvement.
  • Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • The practice had staff recruitment procedures which reflected current legislation.
  • Clinical staff provided patients’ care and treatment in line with current guidelines.
  • 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.
  • Leadership needed strengthening to ensure a culture of continuous improvement.
  • Staff felt involved, supported and worked as a team.
  • Staff and patients were asked for feedback about the services provided.
  • Complaints were dealt with positively and efficiently.
  • The practice had information governance arrangements.

Background

No 1 Nursery Road Dental Practice is in Birmingham 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 near the practice. The practice has made reasonable adjustments to support patients with access requirements.

The dental team includes 3 dentists and 1 dental nurse. The practice has 2 treatment rooms.

During the inspection we spoke with 2 dentists and the dental nurse. We looked at practice policies, procedures and other records to assess how the service is managed.

The practice is open: Tuesday to Thursday from 9am to 5.30pm and Friday from 9am to 5pm.

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.

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 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

No.1 Nursery Road Dental Practice is a dental practice providing general dental services on a private basis. The service is provided by two dentists. They are supported by two dental nurses (one of whom was on maternity leave at the time of our inspection). Both of the dentists worked part-time at the practice and one was available to assist with dental nursing duties in the absence of the staff member on maternity leave.

The practice is located near a busy High Street in a commercial area. There is wheelchair access to the practice and a car parking bay for patients with disabilities. The premises consist of a waiting room, two treatment rooms and toilet facilities on the ground floor. The first floor comprises two decontamination rooms used for the cleaning and sterilisation of used dental instruments, an X-ray room, a staff room, an office and toilet facilities. Opening hours are from 9am to 5:30pm on Monday to Friday.

The two practice owners are registered with the Care Quality Commission (CQC) as a partnership. Like individual 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.

Twenty-nine patients provided feedback about the practice. We looked at comment cards patients had completed prior to the inspection and we also spoke with three patients. Overall the information from patients was complimentary. Patients were positive about their experience and they commented that staff were helpful, friendly and professional.

Our key findings were:

  • There was appropriate equipment for staff to undertake their duties, and equipment was well maintained.
  • The practice had systems to assess and manage risks to patients, including infection prevention and control, health and safety, safeguarding and the management of medical emergencies. We identified some areas for improvement and we were told these would be actioned promptly.
  • Patients’ care and treatment was planned and delivered in line with evidence based guidelines, best practice and current legislation; however, the dental care records were not sufficiently detailed to record this.
  • Staff received training appropriate to their roles.
  • Patients told us they found the staff helpful and friendly. Patients commented they felt involved in their treatment and that it was fully explained to them.
  • Patients were able to make routine and emergency appointments when needed.
  • The practice had an effective complaints process in place and the practice was able to demonstrate they made improvements as a direct result of patient feedback.
  • Staff told us they felt well supported and comfortable to raise concerns or make suggestions.
  • The practice demonstrated that they regularly undertook audits in infection control, radiography and dental care record keeping. However, learning points and action plans were not always documented.

There were areas where the provider could make improvements and should:

  • Review the practice's protocols for completion of dental records giving due regard to guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.
  • Review the protocol for completing accurate, complete and detailed records relating to employment of staff. This includes making appropriate notes of verbal references taken and ensuring recruitment checks, including references, are suitably obtained and recorded. All staff appraisals should be documented.
  • Review the practice’s audit protocols for various aspects of the service, such as dental care records, at regular intervals to help improve the quality of service. The practice should also check all audits have documented learning points and the resulting improvements can be demonstrated.