The Care Quality Commission
  • Dentist
  • Dentist

Archived: Lovat House Dental Surgery

32 Christchurch Road, Cheltenham, Gloucestershire, GL50 2PL (01242) 522841

Provided and run by:
Dr. Paul Macaulay

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

All Inspections

28th March 2017

During a routine inspection

We carried out an announced comprehensive inspection on 28th March 2017 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

Lovat House Dental Practice is located in the centre of Cheltenham and provides private treatment to adults and NHS treatment to children. The practice consists of four treatment rooms, toilet facilities for patients and staff, a reception area and waiting area.

The practice offers routine examinations and treatment. There is one dentist, who is also the registered provider, two dental hygienists, one dental nurse and two receptionists. This provider shares the facilities in the practice with two other dentists who are also registered separately as providers.

The practice’s opening hours are

Monday to Thursday 9am to 1pm and 2pm to 5pm

Out of hours the three dentists took turns to be on-call and patients were directed to phone the dentist on-call.

We carried out an announced, comprehensive inspection on 28th March 2017. The inspection was led by a CQC inspector who was accompanied by a specialist dental advisor.

For this inspection 6 people provided feedback to us about the service. Patients were positive about the care they received from the practice. They were complimentary about the service offered, which they said was excellent. They told us that staff were skillful, professional, helpful, courteous and respectful and the practice was clean and hygienic.

Our key findings were:

• Safe systems and processes were in place, including a lead for safeguarding. 

• Staff recruitment needed to be improved because relevant checks had not been conducted for the most recent person employed. Staff received relevant training.

• The practice had ensured that some risk assessments were in place. We found there was no Legionella risk assessment and the fire risk assessment had not been carried out by an appropriately qualified person.

• The clinical equipment in the practice was appropriately maintained. The practice appeared visibly clean throughout although parts of the surgery were cluttered.

•The process for decontamination of instruments followed relevant guidance.

• The practice maintained appropriate dental care records and patients’ health details were updated. We found some clinical details were not always recorded.

• Patients were provided with health promotion advice to promote good oral care.

• Consent was obtained for dental treatment.

• The dentist was aware of the process to follow when a person lacked capacity to give consent to treatment.

• All feedback that we received from patients was positive; they reported that it was a professional, helpful, courteous, compassionate and respectful service.

• There were arrangements for governance at the practice such as systems for auditing infection control, radiographs and patient records.

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

  • Review the recruitment procedures to ensure that Disclosure and Barring Service (DBS) and references are obtained before new staff start work in the practice in line with current guidance.
  • Review the arrangements for support to staff to make sure all staff receive regular appraisals and personal development plans..
  • Review the arrangements for fire safety to make sure the fire safety measures are in place including a fire risk assessment.
  • Review the arrangements for prevention of Legionella.
  • Review the layout of the surfaces and cupboards in the surgery and the room with the X-ray developer to make sure they are clutter free and easy to clean.
  • Review the storage of paper records to make sure that patient records are stored securely to ensure confidentiality.
  • Review the arrangements for communication to include a hearing loop for patients with a hearing impairment and access to a translation service for people whose first language is not English.
  • Review the arrangements for recording patient information to make sure that following a Basic Periodontal Examination (BPE) the scores are always recorded.
  • Review the arrangements for obtaining patient feedback to make sure questionnaires are reviewed at regular intervals and improvements are identified as a result of feedback.
  • Review the arrangements for auditing to make sure the infection control audits are conducted every six months and are more in depth and include action plans and learning outcomes.

During a check to make sure that the improvements required had been made

When we completed this review we found that the Department of Health Infection Prevention Society (IPS) audit of infection control procedures sent to CQC had been completed thoroughly to identify areas for improvement. The improvements were planned to be completed by November 2013. Two members of staff were given responsibility to ensure that infection control procedures had been completed and IPS audits were completed six monthly.

29 April 2013

During a routine inspection

When we visited the practice we observed the reception staff communicating with patients in a polite and helpful manner. We spoke to the both the dental nurses, a hygienist and the dentists. We also spoke to six patients at the practice and they told us, "choices of treatment were explained", "one of my children was referred to an orthodontist", "excellent treatment, all options were explained" and "the dentist told me upfront about the costs".

Information leaflets were available about the practice and patient's had completed quality surveys, which had been taken into consideration by the dentists when planning improvements. The surveys also included positive comments about the practice. Patients had a full dental assessment and their medical history, medication and allergies had been recorded. Treatment was discussed with the dentists and options were explained and recorded.

All clinical staff had been appropriately trained and had completed their continuing professional development within five year periods to maintain their registration with the General Dental Council. There were systems in place to reduce the risk and spread of infection but there were no audits completed to ensure the decontamination systems were effective.

23 March 2012

During a routine inspection

One person told us they have always had good treatment from Dr MacCauley. They said that he always explains the treatment and listens if they have any concerns. They told us they found the practice was always clean and the nurse helpful. The person said they never worry or feel nervous about their treatment.

Another person we contacted told us they had been with the practice since Dr MacCauley took over. They described him as professional and said he put them at ease. They spoke of how the practice responded to emergencies, "the nice reception staff" and the cleanliness of the building.

We also spoke with the parent of a young person. They told us they also attended the practice and found it to be good. They said they appreciated the range of leaflets that were available and that there were sufficient toys and books to keep their child occupied while waiting for their appointment.