The Care Quality Commission
  • Dentist
  • Dentist

Theydon Dental Surgery Also known as ME Smile Ltd

23 Forest Drive, Theydon Bois, Essex, CM16 7HA (01992) 813951

Provided and run by:
ME Smile Ltd

Important: The provider of this service changed. See old profile

All Inspections

23 January 2024

During a routine inspection

We carried out this announced comprehensive inspection on 23 January 2024 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 practice had infection control procedures which reflected published guidance.
  • Not all staff had received training to manage medical emergencies.
  • Appropriate medicines and life-saving equipment were not always available. The practice took immediate action to replace missing items.
  • The practice had systems to manage risks for patients, staff, equipment and the premises. We found shortfalls in the systems to manage risks within the premises. These included staff training, sharps safety and radiography. The practice took immediate action to mitigate these risks.
  • 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.
  • Clinical staff provided patients’ care and treatment in line with current guidelines.
  • Patients were treated with dignity and respect. Staff took care to protect patients’ privacy and personal information.
  • Staff provided preventive care and supported patients to ensure better oral health.
  • The appointment system worked efficiently to respond to patients’ needs.
  • The frequency of appointments was agreed between the dentist and the patient, giving due regard to National Institute of Health and Care Excellence (NICE) guidelines.
  • There was effective leadership and a culture of continuous improvement.
  • Staff felt involved, supported and worked as a team.
  • Staff and patients were asked for feedback about the services provided.
  • Complaints were dealt with positively and efficiently.
  • The practice had information governance arrangements.

Background

Theydon Dental Surgery is in Theydon Bois, Essex and provides 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 dedicated parking for disabled people, are available near the practice. The practice has made reasonable adjustments to support patients with access requirements.

The dental team includes 2 dentists, 2 trainee dental nurses, 1 dental hygienist, 1 dental therapist and 1 receptionist. The practice has 2 treatment rooms.

During the inspection we spoke with 1 dentist, 1 dental nurse and the receptionist. We looked at practice policies, procedures and other records to assess how the service is managed.

The practice is open:

Monday from 8.30am to 5.30pm.

Tuesday, Wednesday, Thursday and Friday from 8.30am to 3pm.

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

  • 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.
  • Develop systems to ensure an effective process is established for the on-going assessment, supervision and appraisal of all staff. Including the training, learning and development needs of individual staff members at appropriate intervals. In addition, 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.
  • Take action to ensure the suitability of the premises and ensure all areas are fit for the purpose for which they are being used. In particular, ensure any risks and actions highlighted in the Legionella risk assessment and fire risk assessment reports have been mitigated and the premises are safe for use.

22 April 2015

During a routine inspection

We carried out an announced comprehensive inspection on 22 April 2015.

The practice has one dentist who is also the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons 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 dentist is supported by a dental nurse, one trainee dental nurse (also a receptionist) and a dental hygienist that attends the practice monthly.

The practice provides primary dental services to private patients only. This includes patients subscribing to a dental plan in addition to those patients who pay per visit/treatment. The practice is open on Mondays between 8.30am and 5.30pm and on all other weekdays from 8.30am to 3.30pm. to The practice is also open on Saturdays by appointment only.

We spoke with three patients during the inspection. They told us that they were very satisfied with the services provided, that the dentists provided them with clear explanations about their care and treatment, that costs were clear and that all staff treated them with dignity and respect.

We viewed CQC comment cards that had been left for patients to complete, prior to our visit, about the services provided. There were 16 completed comment cards and all of them reflected positive comments about the staff and the services provided. Patients commented that the practice was clean and hygienic, they found it easy to book an appointment and they found the quality of the dentistry to be excellent. They said explanations were clear and that the staff were kind, caring and reassuring. Patients also commented about the availability of a dentist when urgent treatment was required.

The provider was providing care which was safe, effective, caring, responsive and well-led and the regulations were being met.

Our key findings were:

  • The practice had a system in place to record and analyse significant events, safety issues and complaints and to cascade learning to staff
  • Where complaints or mistakes had been made patients were notified about the outcome of any investigation and given a suitable apology
  • Staff had received safeguarding and whistleblowing training and knew the processes to follow to raise any concerns
  • There were sufficient numbers of suitably qualified staff to meet the needs of patients
  • Staff had been trained to handle emergencies and appropriate medicines and life-saving equipment were readily available
  • Infection control procedures were robust and the practice followed published guidance.
  • Patient’s care and treatment was planned and delivered in line with evidence based guidelines, best practice and current legislation
  • Patients received clear explanations about their proposed treatment, costs, benefits and risks and were involved in decisions about it
  • Patients were treated with dignity and respect and confidentiality was maintained
  • The appointment system met the needs of patients and waiting times were kept to a minimum
  • There was an effective complaints system and the practice was open and transparent with patients if a mistake had been made.
  • The practice was well-led and staff felt involved and worked as a team
  • Governance systems were effective and there was a range of clinical and non-clinical audits to monitor the quality of services
  • The practice sought feedback from staff and patients about the services they provided.

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

  • Ensure that learning from practice meetings is recorded and cascaded to staff and areas for improvement are actioned in a timely manner.
  • Ensure infection control audits are undertaken every six months in accordance with the guidance.
  • Update radiation protection documentation to identify those currently responsible for oversight of equipment and operation of it.