The Care Quality Commission
  • Dentist
  • Dentist

Copse Lane Dental Surgery

Copse Lane, Hamble, Southampton, Hampshire, SO31 4QH (023) 8045 7646

Provided and run by:
Ashkan Pitchforth and Manar Elalami

All Inspections

30/11/2023

During an inspection looking at part of the service

We undertook a follow up focused inspection of Copse Lane Dental Surgery on 30 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 previously undertaken a follow up focused inspection of Copse Lane Dental Surgery on 2 August 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), 16 (Receiving and acting on complaints), 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 Copse Lane Dental Surgery 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 2 August 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 2 August 2023.

Background

Copse Lane Dental Surgery is part of South Cliff Dental Group, a dental care provider group.

Copse Lane Dental Surgery is in Hamble and provides NHS and private dental care and treatment for adults and children.

There is step free access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including parking for people with disabilities, are available on site.

The dental team includes 3 trainee dental nurses, 1 dental hygienist, 4 dental therapists, 3 receptionists, 1 administrator, 1 assistant practice manager and a practice manager (who is a qualified dental nurse). The practice has 5 treatment rooms.

During the inspection we spoke with 1 trainee dental nurse, 1 dental therapist, the practice manager, the compliance manager and one of the partners. We looked at practice policies, procedures and other records to assess how the service is managed.

The practice is open:

Monday to Friday 8am to 5.30pm

Saturday 8.30am to 5pm

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

  • Improve the practice's systems for checking and monitoring equipment taking into account relevant guidance and ensure that all equipment and facilities are well maintained.
  • Take action to ensure that all clinical staff have adequate immunity for vaccine preventable infectious diseases.
  • Take action to ensure staff have received training to manage medical emergencies taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.

2 August 2023

During an inspection looking at part of the service

We undertook a follow up focused inspection of Copse Lane Dental Surgery on 2 August 2023 due to the nature of concerns identified during the inspection on 23 February 2023. We are undertaking enforcement action in relation to the regulatory breaches identified. We will report further when any enforcement action is concluded.

This inspection was carried out to review the actions taken by the registered provider to improve the quality of care.

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

We had previously undertaken a comprehensive inspection of Copse Lane Dental Surgery on 23 February 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 and well-led care and was still in breach of regulation 12, safe care and treatment; 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.

You can read our report of that inspection by selecting the 'all reports' link for Copse Lane Dental Surgery 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 23 February 2023.

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 23 February 2023.

Background

Copse Lane Dental Surgery is part of South Cliff Dental Group, a dental care provider group.

Copse Lane Dental Surgery is in Hamble and provides NHS and private dental care and treatment for adults and children.

There is step free access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including parking for people with disabilities, are available on site.

The dental team includes 1 dentist, 4 trainee dental nurses, 3 dental hygienists, 3 dental therapists and 4 receptionists. The practice has 5 treatment rooms.

During the inspection we spoke with 1 dentist, 3 trainee dental nurses, 2 dental therapists, 1 receptionist, a practice manager and a practice support manager. We looked at practice policies, procedures and other records to assess how the service is managed.

The practice is open:

Monday to Friday 8am to 5.30pm

Saturday 8.30am to 5pm

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 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 specified information is available regarding each person employed

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.

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

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

23 February 2023

During a routine inspection

We carried out this unannounced comprehensive inspection on 23 February 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 second inspector and 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 was poorly maintained and visibly dirty in most areas.
  • The practice had ineffective infection control procedures which did not reflect published guidance.
  • Staff knew how to deal with medical emergencies. Most medicines and life-saving equipment were available. Staff were unaware of systems and processes to ensure medical emergency equipment and drugs were checked as recommended by national guidance.
  • The practice had ineffective systems to manage risks for patients, staff, equipment and the premises.
  • Safeguarding processes were ineffective, and staff were not clear on their responsibilities for safeguarding vulnerable adults and children.
  • The practice did not have effective systems and processes to ensure safe recruitment of staff.
  • Clinical staff provided patients’ care and treatment in line with current guidelines.
  • Patients were treated with dignity and respect.
  • Patients’ personal information was not always protected.
  • Staff provided preventive care and supported patients to ensure better oral health.
  • Dental professionals worked to respond to patients’ needs.
  • There was ineffective leadership and a lack of managerial and clinical oversight.
  • There were no systems to obtain staff or patients feedback about the service provided.
  • The processes for dealing with complaints were ineffective.
  • The practice information governance arrangements were ineffective.

Background

The provider is part of a corporate group. South Cliff Dental Group has 27 practices, and this report is about Copse Lane Dental Surgery.

Copse Lane Dental Surgery is in Hamble and provides NHS and private dental care and treatment for adults and children.

There is step free access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including parking for people with disabilities, are available on site. The practice did not always consider patients’ access requirements.

The dental team includes 3 dentists, 1 trainee dental nurse, 2 dental hygienist/therapists, 1 practice manager and 4 receptionists. The practice has 5 treatment rooms.

During the inspection we spoke with 2 dentists, 2 dental nurses provided by an agency, 1 receptionist and the practice manager. We also spoke to the compliance manager and area manager for the company. We looked at practice policies, procedures and other records to assess how the service is managed.

The practice is open:

Monday to Friday 8am to 5.30pm

Saturday 8.30am to 5pm

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

  • Ensure care and treatment is provided in a safe way to patients
  • 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 specified information is available regarding each person employed

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 the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment. In particular, by using rectangular collimators to reduce the patient exposure to radiation whilst receiving an X-ray.

Due to the nature of concerns identified during the inspection on 23 February 2023, we served a Notice of Decision on the provider, to vary a condition on their registration which specifies the locations they are authorised to carry on the regulated activities, so they are no longer authorised to carry on the regulated activities from the location Copse Lane Dental Surgery. The provider has the right to appeal within 28 days of the date the notice was served on them.

6 November 2019

During a routine inspection

We carried out this announced inspection on 6 November 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 providing well-led care in accordance with the relevant regulations.

Background

Copse Lane Dental Surgery is in Hamble and provides NHS and private dental treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces, including those for blue badge holders, are available near the practice.

The dental team includes three dentists, three trainee dental nurses, one dental hygienist, one practice manager and three receptionists. The practice has five treatment rooms.

The practice is owned by a company 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 Copse Lane Dental Surgery is the principal dentist. A registered manager is legally responsible for the delivery of services for which the practice is registered

On the day of inspection, we collected 45 CQC comment cards filled in by patients and spoke with four other patients.

During the inspection we spoke with three dentists, three trainee dental nurses, two receptionists and the principle dentist. The team were also supported by an operations manager, two other practice managers and a 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 8am to 5.30am

Saturday 9am to 5.30pm

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.
  • The provider had systems to help them manage risk to patients and staff.
  • Improvements could be made to the Control of Substances Hazardous to Health (COSHH) Regulations 2002 file to ensure the safe use of materials.
  • The practice should review the use of antibiotic auditing and antibiotic stewardship in line with guidance.
  • The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • The provider had thorough staff recruitment procedures.
  • 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 appointment system took account of patients’ needs.
  • The provider had effective leadership and 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.
  • The provider had suitable information governance arrangements.

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

  • Improve the practice's processes for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken and the products are stored securely.

  • Implement audits for prescribing of antibiotic medicines taking into account the guidance provided by the Faculty of General Dental Practice.