Archived: Mr Ashruf Peer - Bicester

We carried out this announced comprehensive inspection on 17 April 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’s infection control procedures were not effective.
• Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
• Improvements were needed to systems to manage risks for patients, staff, equipment and the premises.
• Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
• Staff recruitment procedures were not operated effectively.
• Clinical staff provided patients’ care and treatment in line with current guidelines.
• Patients were treated with respect.
• Improvements were needed to protocols to protect patients’ privacy.
• 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.
• There was effective 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.

Background

Ashruf Peer Bicester, trading as Bicester Dental Care. is in Bicester and provides NHS and 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:

• 2 dentists
• 1 practice manager (who is also a nurse)
• 2 student dental nurses

The practice has 3 treatment rooms.

During the inspection we spoke with 2 dentists, 2 trainee dental nurses, and the practice manager.

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

The practice is open:

• Monday 8.00am to 5.30pm
• Tuesday 8.00am to 5.30pm
• Wednesday 8.00am to 5.30pm
• Thursday 8.00am to 5.30pm
• Friday 8.00am to 12.30pm

We identified regulations the provider was/is 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 protocols to ensure patient referrals to other dental or health care professionals are centrally monitored to ensure they are received in a timely manner and not lost.

The provider accepted the shortfalls that we raised and took immediate action on 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.