The Care Quality Commission
  • Dentist
  • Dentist

Hartcliffe Dental Practice Partnership

104-108 Gatcombe Road, Bristol, BS13 9RG (0117) 964 9895

Provided and run by:
Purple Dental Care

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

All Inspections

4 November 2020

During an inspection looking at part of the service

We undertook a follow up desk-based review of Hartcliffe Dental Practice Partnership on 4 November 2020. 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 Hartcliffe Dental Practice Partnership on 24 July 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 regulations 17 Good governance and 19 Fit and proper persons employed 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 Hartcliffe Dental Practice Partnership on our website www.cqc.org.uk.

As part of this review we asked:

• Is it well-led?

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.

Our findings were:

Are services well-led?

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

The provider had made improvements in relation to the regulatory breaches we found at our comprehensive inspection of 24 July 2019.

Background

Hartcliffe Dental Practice Partnership is in Hartcliffe, Bristol and provides NHS and private treatment for adults and children.

There is level access for people who use wheelchairs and those with pushchairs. On-street car parking spaces are available near the practice.

The dental team includes three dentists, one foundation dentist, one qualified dental nurse, two trainee dental nurses, one dental hygienist, a practice manager, and one receptionist. The practice has three treatment rooms.

The practice is owned by a partnership and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers 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 registered manager at Hartcliffe Dental Practice Partnership is the senior partner.

During our review, we spoke with the provider (also a dentist) and the practice manager. We looked at practice policies and procedures and other records in relation to the breaches of regulation.

The practice is open:

8:30am to 5pm Monday to Friday

Our key findings were:

  • There was an effective system in place to monitor staff training to ensure staff were up to date.
  • New staff employed had an appropriate induction.
  • Action had been taken to ensure fire safety had been risk assessed in accordance with current Legislation and subsequent actions had been identified and completed.
  • Systems to ensure substances hazardous to health had been risk assessed were still in progress.
  • There were effective systems in place to monitor infection control processes.
  • There were effective systems to manage incidents and these were recorded using reporting tools.
  • There were systems in place to review patient dental care records at regular intervals.
  • There was an effective system in place to ensure policies and procedures were kept up to date with current guidelines.
  • Specified information was available for each person employed, according to legislation and where this had not been possible there was a risk assessment in place
  • Clinical staff had been risk assessed where staff they were either non-responders or not fully immunised for Hepatitis B.
  • An audit had been carried out for prescribing antibiotics taking into account the guidance provided by the Faculty of General Dental Practice.
  • There were procedures in place in relation to the Accessible Information Standard to ensure that the requirements were complied with.

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

  • Review the 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.
  • Improve audits, in particular, clinical records, to ensure they have clearly documented learning points and the resulting improvements can be demonstrated.

24 July 2019

During a routine inspection

We carried out this announced inspection on 24 July 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

Hartcliffe Dental Practice Partnership is in Hartcliffe, Bristol and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. There was no specific practice car parking. However, there was plenty of on-street parking available near the practice.

The dental team includes two dentists and three additional long term locum dentists, one dental nurse, three trainee dental nurses, one dental hygienist, and one receptionist. The practice has three treatment rooms.

The practice is owned by a partnership and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers 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 registered manager at Hartcliffe Dental Practice Partnership is Dr Mohammed Ghafoor, the senior partner.

On the day of inspection, we collected 33 CQC comment cards filled in by patients and spoke with three other patients.

During the inspection we spoke with the principal dentist, who is also the practice manager, two locum dentists, one qualified dental nurse, three trainee dental nurses and one receptionist. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

8:30-5pm Monday to Friday

Our key findings were:

  • The practice appeared clean and well maintained.
  • The provider had infection control procedures which reflected published guidance. Although we noted a couple of areas which could be improved.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
  • The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • The clinical staff provided patients’ care and treatment in line with current guidelines.
  • Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • Staff provided preventive care and supporting patients to ensure better oral health.
  • The appointment system took account of patients’ needs.
  • Staff felt involved, supported and worked well as a team.
  • The provider asked patients for feedback about the services they provided.
  • The provider dealt with complaints positively and efficiently.
  • The provider had suitable information governance arrangements.
  • The provider needed to improve how they recruited staff.
  • The provider had areas where governance could be improved. This included how incidents and staff inductions were managed, and ensuring policies and procedures including current practices and were reviewed regularly.
  • The systems to manage risk to patients and staff could be improved. This included managing infection control, substances hazardous to health, fire safety and staff training in infection control, medical emergencies and safeguarding.

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
  • Ensure specified information is available regarding each person employed

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

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

  • Review the practice’s protocols for ensuring that all clinical staff have adequate immunity for vaccine preventable infectious diseases.
  • Review the practice protocols regarding audits for prescribing of antibiotic medicines taking into account the guidance provided by the Faculty of General Dental Practice.
  • Review the practice’s protocols and procedures in relation to the Accessible Information Standard to ensure that that the requirements are complied with.
  • Review the practice's procedures 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.