Pomeroy & Rust Dental Practice

We carried out this announced comprehensive inspection on 31 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 provider’s infection control procedures were not operated effectively.
• The appointment system worked efficiently to respond to patients’ needs.
• The provider did not operate effective systems to help them manage risk to patients and staff.
• Staff knew how to deal with medical emergencies, but improvement was needed to ensure emergency equipment was appropriate.
• The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The provider’s staff recruitment procedures were not operated effectively.
• Staff provided preventive care and supported patients to ensure better oral health.
• Staff training was not monitored effectively.
• The provider did not have effective leadership and a culture of continuous improvement.
• Staff and patients were asked for feedback about the services provided.
• Complaints were dealt with positively and efficiently.

Background

Pomeroy and Rust is in Bicester and provides private dental care and treatment for adults and children.

The practice is based on the first floor which is a barrier to wheelchair users and people with limited mobility. Patients are advised of this when they contact the practice.

The dental team includes 3 dentists, 3 dental nurses, of which one is a receptionist until their immunity to hepatitis is known, 1 dental hygienist and a head receptionist who supported the provider with administration duties.

The practice has 4 treatment rooms of which 3 are in use.

During the inspection we spoke with 1 dentist, 1 dental nurse, 1 dental hygienist , 1 receptionist and a head receptionist.

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

The practice is open:

• Monday 9.00am to 5.30pm
• Tuesday 9.00am to 5.30pm
• Wednesday 8.00am to 5.30pm
• Thursday 9.00am to 5.30pm
• Friday 9.00am to 7.00pm
• Saturday 9.00am to 3.00pm

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.

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.
• Take action to ensure an automated external defibrillator (AED) is available immediately to manage medical emergencies, taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council, and undertake a risk assessment if a decision is made not to have an AED on site.
• Implement an effective system for receiving and responding to patient safety alerts, recalls and rapid response reports issued by the Medicines and Healthcare products Regulatory Agency, the Central Alerting System and other relevant bodies, such as Public Health England.
• Take action to ensure that all clinical staff have adequate immunity for vaccine preventable infectious diseases.

The provider accepted the shortfalls that we raised and took immediate action the day of our inspection to begin to address these.

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.