The Care Quality Commission
  • Dentist
  • Dentist

Malvern Spring Dental Practice

58 Spring Lane, Malvern, Worcestershire, WR14 1AJ (01684) 567111

Provided and run by:
Dr. Tamjid Mirza

All Inspections

21 March 2024

During a routine inspection

We carried out this announced comprehensive inspection on 21 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. Appropriate medicines and life-saving equipment were available.
  • Some systems to manage risks for patients, staff, equipment and the premises needed strengthening including, prescription management, use of rubber dam and completion of dental care records.
  • 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.
  • There was effective leadership and 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

Malvern Spring Dental Practice is in Malvern, Worcestershire 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, 4 dental nurses (including 1 trainee dental nurse), 1 practice manager, 1 business manager and 1 receptionist. The practice has 3 treatment rooms.

During the inspection we spoke with 1 dentist, 2 dental nurses, the practice manager, the business manager and the receptionist. We looked at practice policies, procedures and other records to assess how the service is managed.

The practice is open: Monday to Friday from 9am to 5pm.

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

  • Ensure there are systems in place to track and monitor the use of NHS prescription pads.
  • Take action to ensure dentists are aware of the guidelines issued by the British Endodontic Society for the use of rubber dam for root canal treatment.
  • Take action to ensure the clinicians take into account the guidance provided by the College of General Dentistry when completing dental care records.

5 September 2017

During a routine inspection

We carried out this announced inspection on 5 September 2017 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

Malvern Spring Dental Practice is located in the spa town of Malvern, Worcestershire and provides predominantly NHS treatments with some private upgrades to patients of all ages.

There is level access for people who use wheelchairs and pushchairs. The ground floor of the practice consists of a reception area, a waiting room, a patient toilet, two dental treatment rooms, a decontamination room for the cleaning, sterilising and packing of dental instruments and room used for storing stock and cleaning materials. On the first floor there is a staff room / kitchen, staff toilet and changing facilities, a practice management office and one dental treatment room. Car parking spaces, including one for blue badge holders, are available directly outside the practice in their dedicated car park.

The dental team includes two dentists, one dental hygiene therapist, four dental nurses (who also support on reception), one trainee dental nurse, one decontamination assistant, one receptionist and a practice manager who is also a qualified dental nurse. The practice has three treatment rooms.

The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.

On the day of inspection we collected 44 CQC comment cards filled in by patients and looked at results from recent friends and family test and practice patient satisfaction surveys. This information gave us a positive view of the practice.

During the inspection we spoke with two dentists, two dental nurses, one dental hygiene therapist, one decontamination room assistant, one receptionist and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Friday: 9am – 5pm

Our key findings were:

  • Strong and effective leadership was provided by the principal dentist and an empowered practice manager.
  • The practice was visibly clean and well maintained.
  • The practice had well organised systems to assess and manage infection prevention and control which reflected published guidance.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
  • The practice had systems to help them manage risk. The practice had an established process for reporting and recording significant events and accidents to ensure they investigated these and took remedial action.
  • The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
  • The practice had thorough staff recruitment procedures.
  • The clinical staff provided dental care in accordance with current professional and National Institute for Care Excellence (NICE) guidelines.
  • Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • The appointment system met patients’ needs. Patients could access treatment and urgent and emergency care when required.
  • The practice asked staff and patients for feedback about the services they provided.
  • The practice dealt with complaints positively and efficiently.
  • Staff had received training appropriate to their roles and were supported in their continued professional development by the principal dentist and practice manager.
  • Staff we spoke with felt well supported by the principal dentist and practice manager and were committed to providing a quality service to their patients.

5 February 2013

During a routine inspection

As part of this inspection we spoke on the telephone with six people who used the practice, two practice managers, a dentist, a receptionist and three dental nurses.

People that used the practice were very complimentary about the care and treatment they received and told us they were given enough information about their treatment options.

One person we spoke with told us, 'I think it (the care) is incredible, so, so good. The care X (the dentist) gives is second to none. X (the dentist) doesn't give in'.

We found that the practice was clean and well organised and there were arrangements in place to ensure equipment was cleaned after use.

The dentists and staff that worked at the practice were suitably qualified and were supported by the provider to maintain their continuous professional development (CPD). In addition to this staff received training on how to recognise signs of abuse, action they should take if they suspected abuse and who to contact.

There were arrangements for monitoring the quality of the service. We saw that people were encouraged to provide feedback about the practice and we saw evidence of actions being implemented from this.