The Care Quality Commission
  • Dentist
  • Dentist

Dumbledore Primary Care Centre

London Road, Handcross, Haywards Heath, West Sussex, RH17 6HB (01444) 400088

Provided and run by:
Dumbledore Dental Care Limited

All Inspections

29/11/2023

During an inspection looking at part of the service

We undertook a follow up focused inspection of Dumbledore Primary Care Centre on 29 November 2023. This inspection was carried out to review 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 led by a CQC inspector who was supported by a specialist dental advisor.

We had undertaken a follow up inspection of Dumbledore Primary Care Centre on 26 April 2023 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 safe or well-led care and was in breach of regulations 12 (Safe care and treatment), 17(Good governance), 18 (Staffing) 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 Dumbledore Primary Care Centre on our website www.cqc.org.uk.

As part of this inspection we asked:

  • Is it safe?
  • Is it well-led?

Our findings were:

Are services safe?

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

The provider had made improvements in relation to the regulatory breaches we found at our inspection on 26 April 2023.

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 inspection on 26 April 2023.

Background

Dumbledore Primary Care Centre is part of South Cliff Dental Group, a group dental provider.

Dumbledore Primary Care Centre is in Handcross and provides NHS and private dental care and treatment for adults and children.

The dental practice is located within a shared healthcare premises with a GP surgery. There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for disabled people, are available outside the practice.

The dental team includes 4 dentists, 8 trainee dental nurses, 2 dental hygienists, 3 dental therapists, 2 receptionists and a practice manager (who is a qualified dental nurse). The practice has 3 treatment rooms.

During the inspection we spoke with 1 dentist, 2 trainee dental nurses, 2 receptionists, the compliance manager and one of the company directors. We looked at practice policies, procedures and other records to assess how the service is managed.

The practice is open:

Monday to Friday from 8.30am to 5.30pm

Saturday from 9.30am to 5.30pm

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

  • Improve the practice's recruitment policy and procedures to ensure accurate, complete and detailed records are maintained for all staff.
  • Improve the practice's liaison with the medical centre to ensure monthly water temperature checks of sentinel outlets are carried out and recorded.

26 April 2023

During an inspection looking at part of the service

We undertook a follow up focused inspection of Dumbledore Primary Care Centre on 26 April 2023. This inspection was carried out to review the actions taken by the registered provider following our previous inspections, to improve the quality of care and to confirm that the practice was now meeting legal requirements.

The inspection was led by a CQC inspector who was supported by a second inspector and a specialist dental advisor.

We undertook a focused responsive inspection of Dumbledore Primary Care Centre on 20 and 21 October 2021 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 safe or well led care and was in breach of regulation 12, safe care and treatment; regulation 13, safeguarding service users from abuse and improper treatment; regulation 16, complaints, regulation 17, good governance; regulation 18, staffing and regulation 19, fit and proper persons employed, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Enforcement action was taken.

We undertook a focused follow-up inspection on 16 February 2022 and found the service was still not providing safe or well led care and breaches were outstanding for regulation 12, 17, and 18, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Further enforcement action was taken.

We undertook a further focused follow-up inspection on 10 August 2022. Some improvements had been made, however, the practice was still in breach of regulation 17, good governance.

A focused follow-up inspection was carried out on 13 October 2022. We found the registered provider was no longer providing safe care and was still not providing well led care. The practice was in breach of regulation 12, regulation 15, 17 and regulation 18. Following receipt of information and evidence of improvements, the enforcement level was downgraded but the provider remained in breach of regulation 17. On our inspection on 26 April 2023 we identified that previous improvements had not been maintained.

You can read our reports of the inspections by selecting the 'all reports' link for Dumbledore Primary Care Centreon our website www.cqc.org.uk.

When 1 or more of the 5 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 safe?
  • Is it well-led?

Our findings were:

Are services safe?

We found this practice was not providing safe care in accordance with the relevant regulations.

The provider had made insufficient improvements to put right the shortfalls and had not responded to the regulatory breaches we found at our inspection on 13 October 2022.

Are services well-led?

We found this practice was not providing well-led care in accordance with the relevant regulations.

The provider had made insufficient improvements to put right the shortfalls and had not responded to the regulatory breaches we found at our inspection on 13 October 2022.

Background

Dumbledore Primary Care Centre is part of South Cliff Dental Group, a group dental provider.

Dumbledore Primary Care Centre is in Handcross and provides NHS and private dental care and treatment for adults and children.

There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for disabled people, are available outside the practice.

The dental team includes 2 dentists, 5 locum dentists, 1 dental therapist, 3 trainee dental nurses, 5 receptionists and a practice manager. The practice has 3 treatment rooms.

During the inspection we spoke with 2 dentists, 2 trainee dental nurses, the practice manager who is also a trainee dental nurse and the compliance manager for the company. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Friday from 8.30am to 5.30pm

Saturday from 9.30am to 5.30pm

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

  • Ensure care and treatment is provided in a safe way to patients
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
  • Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed
  • Ensure specified information is available regarding each person employed

We will report further when any enforcement action is concluded.

13 October 2022

During a routine inspection

We undertook a follow-up focused inspection of Dumbledore Primary Care Centre on 13 October 2022. 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 led by a CQC inspector who was supported by a second inspector and a specialist dental adviser.

We undertook a focused responsive inspection of Dumbledore Primary Care Centre on 20 and 21 October 2021 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 safe or well led care and was in breach of regulation 12, safe care and treatment; regulation 13, safeguarding service users from abuse and improper treatment; regulation 16, complaints, regulation 17, good governance; regulation 18, staffing and regulation 19, fit and proper persons employed, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Enforcement action was undertaken.

We undertook a focused follow-up inspection on 16 February 2022 and found the service was still not providing safe or well led care and breaches remained outstanding for regulation 12, safe care and treatment, 17, good governance and 18, staffing, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Further enforcement action was undertaken.

We undertook a further focused follow-up inspection on 10 August 2022. Significant improvements were identified but the practice remained in breach of regulation 17, good governance.

A focused follow-up inspection was carried out on 13 October 2022 to review actions taken by the registered provider in response to our previous findings.

You can read our report of all inspections by selecting the 'all reports' link for Dumbledore Primary Care Centre 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. In addition to the to the areas of required improvement, we had received information of concern. Therefore, as part of this inspection we asked:

• Is it safe?

• Is it well-led?

Our findings were:

Are services safe?

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

Are services well-led?

We found this practice was not providing well-led care in accordance with the relevant regulations.

The provider had made insufficient improvements to put right the shortfalls and had not responded to the regulatory breach we found at our inspection on 10 August 2022.

Background

The provider has 27 practices and this report is about Dumbledore Primary Care Centre.

Dumbledore Primary Care Centre is in Handcross and provides NHS and private dental care and treatment for adults and children.

There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for disabled people, are available outside the practice.

The dental team includes 2 dentists, 1 lead nurse/dental nurse trainer, 5 trainee dental nurses, 3 dental hygienists, and 2 receptionists. The practice has 3 treatment rooms.

During the inspection we spoke with 1 dentist, 1 lead nurse/dental nurse trainer, 1 dental hygienist, 1 receptionist, the covering practice manager, an interim compliance manager and deputy compliance manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Friday from 8.30am to 5.30pm

Saturday from 9.30am to 5.30pm

We identified regulations the provider was not meeting. 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.

10 August 2022

During an inspection looking at part of the service

We carried out this announced comprehensive follow-up inspection on 10 August 2022 under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. 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 led by a CQC inspector who was supported by a second inspector and a specialist dental adviser.

We undertook an unannounced focused inspection of Dumbledore Primary Care Centre on 20 and 21 October 2021 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 safe or well led care and was in breach of regulations 12, 13, 16, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At our follow-up inspection on 16 February 2022, we found that the provider was still not providing safe or well led care and was in breach of regulations 12, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can read our reports of those inspections by selecting the 'all reports' link for Dumbledore Primary Care Centre on our website www.cqc.org.uk.

As part of this inspection we asked:

• 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 was visibly clean and well-maintained although improvements were underway to ensure better oversight of the environmental cleaning.
  • The practice had infection control procedures which reflected published guidance although some minor improvements were still required.
  • Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
  • The practice had implemented systems to help them manage risk to patients and staff more effectively; however, these were newly implemented and further improvements were still required.
  • 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 although improvements in the oversight and monitoring of these was required.
  • The clinical staff provided patients’ care and treatment in line with current guidelines.
  • Patients were treated with dignity and respect and staff took care to protect their privacy and personal information.
  • Staff provided preventive care and supported patients to ensure better oral health.
  • Improvements to the appointment system were underway to ensure it took account of patients’ needs.
  • There were improvements in the overall leadership at the practice and we saw staff were motivated to improve.
  • Staff we spoke to felt more supported and listened to.
  • Improvements were required to the systems in place to obtain feedback from patients about the services provided.
  • We saw that the systems in place to manage complaints required improving and actions were underway to remedy the shortfalls.
  • The dental practice had information governance arrangements.

Background

The provider has 23 practices and this report is about Dumbledore Primary Care Centre.

Dumbledore Primary Care Centre is in Handcross in West Sussex and provides NHS and private dental care and treatment for adults and children. The dental practice is located within a primary care medical centre.

There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for people with disabilities, are available outside the practice.

The dental team currently includes two dentists, two dental nurse trainers, two trainee dental nurses, two dental hygienists and one receptionist. A practice manager from another location has been supporting the practice temporarily as well as a head receptionist/trainer from another location. The compliance manager informed us a number of extra staff members had been recruited recently and they would be starting shortly. The practice has three treatment rooms.

During the inspection we spoke with one dentist, one dental nurse trainer, two trainee dental nurses, one receptionist, the head receptionist/trainer from another location , the practice manager providing temporary cover, the compliance manager, deputy compliance manager and the company’s clinical director. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Friday from 8.30am to 5.30pm

Saturday from 9.30am to 5.30pm

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 is not meeting are at the end of this report.

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

  • Implement processes and systems for seeking and learning from patient feedback with a view to monitoring and improving the quality of the service.

16 February 2022

During an inspection looking at part of the service

We undertook a follow-up focused inspection of Dumbledore Primary Care Centre on 16 February 2022. 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 led by a CQC inspector who was supported by a specialist dental adviser.

We undertook an unannounced focused inspection of Dumbledore Primary Care Centre on 20 and 21 October 2021 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 safe or well led care and was in breach of regulations 12, 13, 16, 17, 18 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 Dumbledore Primary Care Centre dental practice on our website www.cqc.org.uk.

As part of this inspection we asked:

• Is it safe?

• Is it well-led?

Our findings were:

Are services safe?

We found this practice was not providing safe care in accordance with the relevant regulations.

The provider had made insufficient improvements to put right the shortfalls and had not responded to the regulatory breaches we found at our inspection on 20 and 21 October 2021.

Are services well-led?

We found this practice was not providing well-led care in accordance with the relevant regulations.

The provider had made insufficient improvements to put right the shortfalls and had not responded to the regulatory breaches we found at our inspection on 20 and 21 October 2021.

Background

Dumbledore Primary Care Centre is in Handcross in West Sussex and provides NHS and private dental care and treatment for adults and children. The dental practice is located within a primary care medical centre.

There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for people with disabilities, are available outside the practice.

The dental team includes two dentists, two trainee dental nurses, one dental hygienist and three receptionists. On the day of the inspection there was one qualified dental nurse from another practice. The practice has three treatment rooms.

The practice is owned by a company and as a condition of registration must have a person registered with the CQC 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 Dumbledore Primary Care Centre is the director of the company.

During the inspection we spoke with one dentist, one trainee dental nurse, one qualified dental nurse, two receptionists, the compliance manager, the director of the company and administrative support staff for the company. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Saturday from 8.30am to 5.30pm

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

  • Ensure care and treatment is provided in a safe way to patients
  • Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
  • Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed
  • Ensure specified information is available regarding each person employed

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

  • Take action to ensure the clinicians take into account the guidance provided by the National Institute for Health and Care Excellence and the College of General Dentistry when prescribing antimicrobials.

20 October 2021 and 21 October 2021

During an inspection looking at part of the service

We carried out this focused unannounced inspection on 20 October 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 second inspector and a specialist dental adviser.

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 not 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 not providing well-led care in accordance with the relevant regulations.

Background

Dumbledore Primary Care Centre is in Handcross in West Sussex and provides NHS and private dental care and treatment for adults and children. The dental practice is located within a primary care medical centre.

There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for people with disabilities, are available outside the practice.

The dental team includes two dentists, three trainee dental nurses who perform dual roles as receptionist, one dental hygienist and one receptionist. On the day of the inspection there was one qualified agency dental nurse and the compliance manager for the organisation who was temporarily undertaking the role of practice manager. The practice has three treatment rooms.

The practice is owned by a company and as a condition of registration must have a person registered with the CQC 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 Dumbledore Primary Care Centre is the director of the company.

During the inspection we spoke with two dentists, three trainee dental nurses, one qualified dental nurse, the compliance manager, the director of the company and administrative support staff for the company. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Friday from 8.30am to 5.30pm

Our key findings were:

  • 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 supported patients to ensure better oral health.
  • The provider had some information governance arrangements.
  • There were areas of the practice which were cluttered and visibly unclean.
  • The provider had infection control procedures that did not reflect published guidance.
  • Emergency medicines and life-saving equipment was mostly available as per national guidance. However, not all staff knew how to deal with medical emergencies.
  • The provider had ineffective systems to help them manage risk to patients and staff.
  • The provider had ineffective safeguarding processes and not all staff knew their responsibilities for safeguarding vulnerable adults and children.
  • Staff recruitment procedures did not reflect current legislation.
  • There was lack of suitable number of staff to meet patient need.
  • There was ineffective leadership and there was no culture of continuous improvement.
  • Staff did not feel involved or supported.
  • The provider’s system for dealing with complaints was ineffective and staff did not know how to deal with complaints.

We identified regulations the provider was not complying with. They must:

  • Ensure care and treatment is provided in a safe way to patients
  • Ensure patients are protected from abuse and improper treatment
  • Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation
  • Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
  • Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed
  • Ensure specified information is available regarding each person 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:

  • Implement audits for prescribing of antibiotic medicines taking into account the guidance provided by the College of General Dentistry.
  • Improve the practice protocols regarding auditing patient dental care records to check that necessary information is recorded.
  • Improve and develop staff awareness of the requirements of the Mental Capacity Act 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.

8 March 2013

During a routine inspection

We spoke to three patients who confirmed they were pleased with the services they received. One patient told us that he was 'satisfied and they are always very courteous and explain things thoroughly'.

We asked about how a medical emergency could be handled and were told that the facility was shared with a general medical practice. If an alarm was raised, medical assistance would be summoned.

We were shown the summary sheet of the Infection Prevention Society (IPS) audit tool which was used to monitor compliance with HTM 01-05 decontamination guidelines and this showed that the practice had achieved between 93-100% score by following the guidelines.

The practice manager explained that there were two dentists working regularly with two qualified and GDC (General Dental Council) registered nurses.

The manager showed us how he tracked the staff training records using a spreadsheet which contained the details of verifiable training which had been undertaken.

The practice manager explained that patient records that were stored on computer were password protected and paper records were stored in cabinets which were locked when unattended.