Ash Vale Dental Surgery

We carried out this announced focused inspection on 11 January 2022 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:

• The practice was not clean and well-maintained.
• The provider’s infection control procedures were not operated effectively.
• Appropriate medicines and life-saving equipment were not available.
• The provider did not operate effective systems to help them manage risk to patients and staff.
• Staff knew their responsibilities for safeguarding vulnerable adults and children. Improvements were needed to ensure local authority contact details were correct.
• The provider’s staff recruitment procedures were not operated effectively.
• Staff provided preventive care and supported patients to ensure better oral health.
• The provider did not have effective leadership and a culture of continuous improvement.
• Staff felt involved and supported by the provider.
• The provider asked staff and patients for feedback about the services they provided.
• The provider’s information governance arrangements were not operated effectively.

Background

Ash Vale Dental Surgery is in Aldershot and provides NHS and private dental care and treatment for adults and children.

There are steps into the practice. People are made aware of this when they make initial contact.

On street car parking spaces are available outside the practice.

The dental team includes two dentists, two dental nurses and one receptionist.

The practice has two treatment rooms.

During the inspection we spoke with the principal dentist and a dental nurse. The practice was closed to patients on the day of our visit.

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

The practice is open:

• Monday 8.30 am - 4.30 pm
• Tuesday 8.30 am - 4.30 pm
• Wednesday 8.30 am - 4.30 pm
• Thursday 8.30 am – 3.00 pm
• Friday 8.30am – 12 noon
  
  

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

• Ensure care and treatment is provided in a safe way to patients.
• Ensure all premises and equipment used by the service provider is fit for use.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• 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 the duties.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed and 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.

The provider accepted the clinical and managerial issues raised and started to take action to address these.

They advised that the management of Ash Vale would include appointing his nurse as the full-time practice manager, recruiting a replacement nurse and the sourcing of a compliance package to ensure improvements will be made.

Where evidence is sent that shows the relevant issues have been acted on, we have stated this in our report but we cannot say that the practice is compliant for that key question as this would not be an accurate reflection of what was found on the day of our inspection.