The Care Quality Commission
  • Dentist
  • Dentist

Chesham Dental

260-290, Berkhampstead Road, Chesham, Buckinghamshire, HP5 3EZ (01494) 776550

Provided and run by:
Dr Amit Rai

Important: The provider of this service changed - see old profile

All Inspections

15 March 2023

During a routine inspection

We carried out this announced comprehensive inspection on 15 March 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 had infection control procedures which reflected published guidance.
  • Staff knew how to deal with medical emergencies.
  • Appropriate medicines and life-saving equipment were available.
  • The practice had 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.
  • 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 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 worked as a team.
  • Staff and patients were asked for feedback about the services provided.

Background

The practice is part of a group of 6 practices owned by Dr Amit Rai. This report is about Chesham Dental.

Chesham Dental is in Chesham and provides NHS and private dental care and treatment for adults and children.

There is step free access to the practice, via a lift, for people who use wheelchairs and those with pushchairs.

The practice has made reasonable adjustments to support patients with additional access requirements. Adjustments include:

  • A wheelchair accessible toilet
  • Hearing loop
  • Reading aids (magnifying glass)
  • Step free access via a lift

Car parking spaces, including dedicated parking for disabled people, are available outside the practice.

The dental team includes:

  • 4 dentists
  • 1 qualified dental nurse
  • 1 student nurse
  • 1 dental hygienist
  • 2 dental therapists
  • 3 receptionists.
  • 1 practice manager

The practice has 4 treatment rooms.

During the inspection we spoke with 1 dentist, 1 dental nurse, 1 receptionist, and 3 external management support staff.

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

The practice is open:

  • Monday 8.30am to 5.30pm
  • Tuesday 8.30am to 5.30pm
  • Wednesday 8.30am to 5.30pm
  • Thursday 8.30am to 7.00pm
  • Friday 8.30am to 5.30pm

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

  • Improve the practice's protocols and procedures for the use of the orthopantomography (OPG) X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment.

  • Improve the practice's systems for assuring themselves that the checking and monitoring of fire safety equipment is carried out by the landlord’s representative effectively.

  • Improve the practice’s protocols for the use of closed-circuit television cameras taking into account the guidelines published by the Information Commissioner's Office.

  • Improve the practice's complaint handling procedures and establish an effective system for recording complaints by service users.

10/09/2021

During an inspection looking at part of the service

We carried out this announced inspection on 10 September 2021 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 Care Quality Commission, (CQC), inspector who was supported by a specialist dental adviser.

To get to the heart of patients’ experiences of care and treatment, we asked the following three questions:

• Is it safe?

• Is it effective?

• 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 this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

We found this practice was providing effective care in accordance with the relevant regulations.

Are services well-led?

We found this practice was providing well-led care in accordance with the relevant regulations.

Background

Chesham Dental is based in Chesham and provides NHS and private treatment to patients of all ages.

There is step free access, via a lift, for people who use wheelchairs and those with pushchairs.

Car parking spaces, including some for blue badge holders, are available outside the practice.

Chesham Dental has leased space in a building occupied by two GP practices and several health support agencies. The building is owned by a property management company.

The dental team includes four dentists, one hygienist, one qualified dental nurse, four trainee dental nurses, two receptionists and a part time practice manager.

The practice has three treatment rooms, a decontamination room, office and reception.

The practice is owned by an individual. 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.

The provider has chosen to appoint a registered manager at Chesham Dental. This person is the practice manager.

During the inspection we spoke with one dentist, one hygienist, one trainee dental nurse, the practice manager and the provider.

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

The practice is open:

  • Monday 8.30am to 5.30pm
  • Tuesday 8.30am to 8.00pm
  • Wednesday 8.30am to 5.30pm
  • Thursday 8.30am to 8.00pm
  • Friday 8.30am to 5.30pm
  • Saturday 8.30am to 1.00pm

.

Our key findings were:

  • The practice appeared to be visibly clean and well-maintained.
  • The provider had infection control procedures which reflected published guidance.
  • Staff knew how to deal with medical emergencies. Medical emergency equipment ‘use by’ dates were not included in regular checks.
  • The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • Antibiotic prescribing audits were carried out.
  • Patient referrals to other health providers were not centrally monitored to ensure they were received in a timely way and not lost.
  • The provider had effective staff recruitment procedures which reflected current legislation.
  • The clinical staff provided patients’ care and treatment in line with current guidelines and all clinicians maintained detailed patient treatment care records.
  • The provider had information governance arrangements and took care to protect their privacy and personal information.
  • Staff information about the procedure to follow after receiving a sharps injury was not available in the clinical areas of the practice.
  • Staff provided preventive care and supported patients to ensure better oral health.
  • The provider had effective leadership and a culture of continuous improvement.
  • Staff felt involved and supported and worked as a team.
  • The provider asked staff and patients for feedback about the services they provided.

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

  • Implement an effective system of checks of ‘use by dates’ for medical emergency equipment taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.

  • Take action to ensure the information about the procedure to follow after receiving a sharps injury is available in the clinical areas of the practice.

  • Implement a system 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.

27/06/2019

During an inspection looking at part of the service

We undertook a focused inspection of Chesham Dental in Chesham on 27 June 2019. This inspection was carried out to review in detail the actions taken by the registered provider to improve the quality of care and to confirm that the practice was now meeting legal requirements.

The inspection was carried out by a CQC inspector.

We undertook a comprehensive inspection of the practice on the 5 March 2019 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 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can read our report of that inspection by selecting the 'all reports' link for dental practice on our website www.cqc.org.uk.

When one or more of the five questions are not met we require the service to make improvements and send us an action plan. We then inspect again after a reasonable interval, focusing on the areas where improvement was required.

As part of this inspection we asked:

• Is it well-led?

Background

Chesham Dental is based in Chesham and provides NHS and private treatment to patients of all ages.

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

Chesham Dental has leased space in a building occupied by two GP practices and several health support agencies. The building is owned by a property management company. We will refer to the property company as the landlord in this report.

The dental team includes five dentists, one dental nurse, three trainee dental nurses, one hygienist, three receptionists, one clinical lead and a part time practice manager.

The practice has three treatment rooms, a decontamination room, office and reception.

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.

The provider has chosen to appoint a registered manager at Chesham Dental. This person is the practice manager.

During the inspection we spoke with the provider, practice manager and clinical lead.

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

The practice is open:

  • Monday 8.30am to 5.30pm
  • Tuesday 8.30am to 8.00pm
  • Wednesday 8.30am to 5.30pm
  • Thursday 8.30am to 8.00pm
  • Friday 8.30am to 5.30pm
  • Saturday 8.30am to 1.00pm

Our key findings were:

  • The provider had made good improvements in relation to the regulatory breach we found at our previous inspection and was now providing well-led care in accordance with the relevant regulations.

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

  • Review the practice protocols for ensuring that all clinical staff have adequate immunity for vaccine preventable infectious diseases.

05/03/2019

During an inspection looking at part of the service

We carried out this unannounced inspection on 5 March 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 not providing well-led care in accordance with the relevant regulations.

Background

Chesham Dental is based in Chesham and provides NHS and private treatment to patients of all ages.

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

Chesham Dental has leased space in a building occupied by two GP practices and several health support agencies. The building is owned by a property management company. We will refer to the property company as the landlord in this report.

The dental team includes six dentists, five trainee dental nurses, two hygienists, three receptionists and a part time practice manager.

The practice has three treatment rooms, a decontamination room, office and reception.

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.

The provider has chosen to appoint a registered manager at Chesham Dental. This person is the practice manager.

On the day of our inspection we obtained the views of 19 patients.

During the inspection we spoke with three dentists, one trainee dental nurse, the practice manager and the provider. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

  • 8.30am to 5.30pm Monday, Wednesday and Friday
  • 8.30am to 8.00pm Tuesday and Thursday
  • 8.30am to 1.00pm Saturday

Our key findings were:

  • The practice appeared clean and well maintained.
  • The practice had infection control procedures which reflected published guidance but improvements were needed.
  • Staff knew how to deal with emergencies. Improvements were needed to ensure appropriate medicines and life-saving equipment were available.
  • The practice had systems to help them manage risk but did not operate these effectively.
  • The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children but training required improvement.
  • Improvements were needed to staff recruitment procedures.
  • Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • The practice did not ask for patient feedback about the services they provided.
  • The practice was providing preventive care and supporting patients to ensure better oral health.
  • The appointment system met patients’ needs.
  • The management of staff training was not effective.
  • Staff felt involved, supported and worked well as a team.
  • The practice dealt with complaints positively and efficiently.
  • The practice had suitable information governance arrangements.
  • The practice did not have effective clinical and management leadership or a culture of continuous improvement.
  • We have been provided evidence to confirm all but two of the shortfalls identified have been addressed. The two areas outstanding are management of staff training and effective staff recruitment processes.

We identified regulations the provider was not meeting. They must:

  • Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

Full details of the regulations the provider was not meeting are at the end of this report.

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

  • Review the practice protocols for ensuring that all clinical staff have adequate
  • Review the current staffing arrangements to ensure all dental care professionals are adequately supported by a trained member of the dental team when treating patients in a dental setting taking into account the guidance issued by the General Dental Council.
  • Review the practice's processes and systems for seeking and learning from with a view to monitoring and improving the quality of the service.