The Care Quality Commission
  • Dentist
  • Dentist

Henley-in-Arden

215 High Street, Henley In Arden, West Midlands, B95 5BG (01564) 794908

Provided and run by:
Dr. Matthew Jones

All Inspections

9 July 2020

During an inspection looking at part of the service

We undertook a follow up desk-based review of Henley-in-Arden on 9 July 2020. This review was carried out to examine 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 review was led by a CQC inspector.

We undertook a comprehensive inspection of Henley-in-Arden on 24 September 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 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 Henley-in-Arden 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 (requirement notice only). We then review 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 breach we found at our inspection on 24 September 2019.

Background

Henley-in-Arden (also known as Ivory Bespoke Dentistry) is in Henley in Arden and provides NHS and private dental treatment to adults and children. The services are provided under two separately registered providers at this location. This report only relates to the provision of general dental care provided by Dr. Matthew Jones. An additional report is available in respect of the general dental care services which are registered under Ivory Bespoke Dentistry Ltd.

There is access for people who use wheelchairs and those with pushchairs with the use of a portable ramp. Car parking spaces, including spaces for blue badge holders, are available in the free shopper’s car parks near the practice.

The dental team includes the principal dentist, three dental nurses, one dental hygienist and one receptionist. The practice has two 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.

The practice is open:

Monday from 9am to 5pm.

Tuesday from 9am to 6pm.

Wednesday from 9am to 4.30pm.

Thursday from 9am to 4:30pm.

Friday from 9am to 5pm.

Our key findings were:

The provider had made improvements to the management of the service. These included completing analysis and action plans for infection prevention and control audit and radiography audit; completing risk assessments for lone working, sharps and general health and safety; implementing and completing regular review of legionella and fire risk assessments; evidencing appropriate safeguarding training for the practice safeguarding lead; updating recruitment processes; implementing monitoring and tracking systems for prescriptions and improving detail recorded in patients’ dental assessments. These improvements provided a sound footing for the ongoing development of effective governance arrangements at the practice.

24 September 2019

During a routine inspection

We carried out this announced inspection on 24 September 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 two specialist dental advisers.

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

Henley-in-Arden is in Henley in Arden and provides NHS and private dental treatment to adults and children. The services are provided under two separately registered providers at this location. This report only relates to the provision of general dental care provided by Dr. Matthew Jones. An additional report is available in respect of the general dental care services which are registered under Ivory Bespoke Dentistry Ltd.

There is access for people who use wheelchairs and those with pushchairs with the use of a portable ramp. Car parking spaces, including spaces for blue badge holders, are available in the free shopper’s car parks near the practice.

The dental team includes the principal dentist, three dental nurses, one dental hygienist and one receptionist. The practice has two 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 14 CQC comment cards filled in by patients and spoke with two patients.

During the inspection we spoke with the principal dentist, one dental nurse and one receptionist. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday from 9am to 5pm

Tuesday from 9am to 6pm

Wednesday from 9am to 4.30pm

Thursday from 9am to 4:30pm

Friday from 9am to 5pm

Our key findings were:

  • The practice appeared clean and well maintained.
  • The provider had infection control procedures which reflected published guidance.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available, with the exception of clear face masks for the self-inflating bag and a self-inflating bag with reservoir. These items were ordered during the inspection.
  • The provider had insufficient systems to help them manage risk to patients and staff. We found shortfalls in appropriately assessing and mitigating risks in relation to legionella, fire safety, recruitment, prescriptions, record keeping and audit.
  • The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children. We were not shown evidence of safeguarding adults training for the safeguarding lead.
  • The provider’s recruitment procedures were not robust and essential pre-employment information such as references were not obtained for all staff. We were not assured that 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 supported patients to ensure better oral health.
  • The appointment system took account of patients’ needs.
  • The provider did not demonstrate effective leadership and a culture of continuous improvement.
  • Staff felt involved and supported and worked well as a team.
  • The provider asked staff and patients for feedback about the services they provided.
  • The provider dealt with complaints positively and efficiently.
  • Governance arrangements required strengthening.
  • The provider demonstrated they were taking responsive action to the shortfalls we identified following our visit.

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.

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

22 April 2013

During a routine inspection

We inspected this provider previously on the 17 January 2013 and identified that effective recruitment procedures had not always been followed. Since the last inspection the dentist had not recruited any new staff to post and would not be doing so in the near future. We saw that a recruitment protocol is now in place. The provider may like to note that the current recruitment protocol did not fully identify a recruitment and selection procedure that complies with legislation about employment, equalities and human rights.

Some other actions taken by the dentist since our last inspection have included undertaking police checks on all the practice staff and developing a staff induction checklist for new staff.

17 January 2013

During a routine inspection

We spoke with the dentist, three staff and six patients. Patients told us they had been happy with the service provided. Some comments were, ' Have a good ethos at the practice ' and ' When I go in for a check-up I feel I have value for money.' Patients told us they found the staff approachable and would approach them with any concerns. We saw patient satisfaction had been monitored throughout the year and found patient satisfaction to be good.

We saw some systems in place to protect people from the risk of abuse. Discussions with staff showed that they had awareness of what to do, who to approach and the guidance available should safeguarding concerns be identified. During the inspection we also looked at requirements relating to workers as we found some shortfalls in recruitment and pre-employment checks at the practice.

We saw that there were sufficient staff available to accommodate patients' needs. Patient records and discussions with patients confirmed their needs had been assessed, risks identified and personalised plans of care developed for each patient. We saw evidence of joint working with dental specialists to ensure patients' specialist dental healthcare needs had been met. We have asked that the provider may like to note our findings in relation to the current practice of the storage of resuscitation drugs at the practice.