Mr Imran Azmat - Birchfield Road

Background

Mr Azmat’s Dental Practice at 19 Birchfield Road has two dentists who each work part time, two part time dental nurses and a receptionist. All of the dental nurses were qualified and registered with the General Dental Council (GDC). The practice’s opening hours are 9am to 1pm and 2pm to 5pm on Mondays, Tuesdays and Fridays and 9am to 1pm and 2pm to 5.30pm on Wednesday and Thursdays. Appointment times vary slightly from opening times on Monday, Tuesday and Friday with the last appointment being available at 3.30pm.

Mr Azmat’s Birchfield Road Dental Practice provides NHS treatment for both adults and children. The practice is situated in a converted residential property. The practice has two dental treatment rooms; both on the ground floor, one of which has steps to gain access and the other providing access for patients with limited mobility. There is a separate decontamination room for cleaning, sterilising and packing dental instruments. There is also a reception and separate waiting area. The patient toilet is located on the first floor of the building and is therefore not suitable for those patients who would not be able to use stairs to gain access.

Before the inspection we sent Care Quality Commission comment cards to the practice for patients to complete to tell us about their experience of the practice. We collected 12 completed cards and spoke to five patients. These provided a positive view of the services the practice provides. All of the patients commented that the quality of care was good and we were told that staff were friendly and helpful.

We carried out an announced comprehensive inspection on 3 November 2015 as part of our planned inspection of all dental practices. The inspection took place over one day and was carried out by a lead inspector and a dental specialist adviser.

Our key findings were:

• The practice had mechanisms in place to record significant events and accidents.
• There were sufficient numbers of suitably qualified staff to meet the needs of patients.
• Infection control audits were being undertaken on a six monthly basis.
• The practice kept up to date with current guidelines when considering the care and treatment needs of patients.
• Patients were treated with dignity and respect and confidentiality was maintained.
• Health promotion advice was given to patients appropriate to their individual needs such as smoking cessation or dietary advice.
• Staff received regular training and appraisal systems had been implemented effectively.
• The appointment system met the needs of patients and waiting times were kept to a minimum.
• Patients felt involved in all treatment decisions and were given sufficient information, including details of costs to enable them to make an informed choice.
• There were clearly defined leadership roles within the practice and staff told us they felt supported and comfortable to raise concerns or make suggestions.
• The practice sought feedback from staff and patients about the services they provided.
• The practice undertook a rolling programme of clinical audit which showed that a consistent standard was being maintained in relation to standards of patient assessment, infection control and dental radiography.

We identified regulations that were not being met and the provider must:

• Ensure an effective system is establishedto assess, monitor and mitigate the various risks arising from undertaking of the regulated activities. This should include systems to maintain and monitor emergency medicine and equipment, first aid packs and fire systems. Where appropriate fire and X-ray signage must be in place.
• Ensure that actions identified in the legionella risk report dated May 2013 are addressed and an updated assessment is undertaken.
• Ensure that an accurate, complete and contemporaneous record is kept in respect of each patient, including a record of the decisions taken in relation to the care and treatment provided.

You can see full details of the regulations not being met at the end of this report.

There were areas where the provider could make improvements and should:

• Review the training, learning and development needs of individual staff members at appropriate intervals.
• Regular staff meetings should be held to discuss any issues within the practice including significant events, complaints and discuss audit results.
• Undertake reviews and audits of consent and provide consent records that contain full details of conversations held.
• Implement clear procedures for managing comments, concerns or complaints.
• Implement systems to record the batch numbers of all anaesthetic on the premises including that which is located in the stock room.