The Care Quality Commission
  • Dentist
  • Dentist

Mr Imran Azmat - Birchfield Road

19 Birchfield Road, Aston, Birmingham, West Midlands, B19 1SU (0121) 554 1065

Provided and run by:
Mr Imran Azmat

All Inspections

During an assessment under our new approach

We carried out this announced on-site assessment on 19 December 2024.

We found the practice had met regulations.

Recruitment procedures reflected current legislation and there was effective leadership and a culture of continuous improvement.

Patients were treated with dignity and respect and at the time of our assessment, could access care, support and treatment when required.

Patients’ care and treatment was provided in line with current guidance and infection control procedures were in place.

The practice had systems to manage risks.

Mr Imran Azmat – Birchfield Road is in Birmingham and provides NHS and private dental care and treatment for adults and children.

There was step-free access to the practice and car parking spaces, including dedicated parking for disabled people, were available near the practice.

The practice had 2 treatment rooms. During the assessment we spoke with 2 dentists and 1 dental nurse.

29 September 2016

During a routine inspection

We carried out an announced comprehensive inspection on 3 November 2015 as part of our regulatory function where a breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach.

We carried out a focussed review on 29 September 2016 to check whether the practice had taken action to address a breach of Regulation 17(1) and (2)(a)(b)(c)(f) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This report only covers our findings in relation to those requirements. We have not revisited Mr Imran Azmat – Birchfield Road for this review because the registered provider was able to demonstrate that they were meeting the standards without the need for a visit. You can read the report from our previous comprehensive inspection by selecting the ‘all reports’ link for Mr Imran Azmat – Birchfield Road on our website at www.cqc.org.uk

Our findings were:

Are services well-led?

We found that this practice was providing well-led care in accordance with the relevant regulations.

Our key findings were:

  • Overall we found that sufficient action had been taken to address the shortfalls identified at our previous inspection and the provider was now compliant with the regulation.

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

  • Review the practice’s systems for completing checks on emergency equipment and medicines giving due regard to guidelines issued by the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.
  • Review the current legionella risk assessment and implement the required actions, giving due regard to Health Technical Memorandum 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance

3 November 2015

During a routine inspection

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.

30 June 2012

During a routine inspection

Before our visit told, we told the provider that we were coming. The provider is also the practising dentist at the practice. We asked the provider to inform people who would be visiting the dentist on the day of our visit and advice them that we may speak with them.

During our visit, we spoke with one person using the service, two dental nurses, the provider and another dentist. Following our visit, we spoke with five people on the telephone to seek their views about the service provided. We looked at the records for five people who had used the service. It was not appropriate to speak to more then one person during our visit.

People were complimentary about the service and said that the staff made them feel welcome. They told us any treatment they had was fully explained to them. One person told us 'I have been going to this practice since I was 10 years old I am now 80 so must it be good.' and they added 'It is very well run, both now and by the predecessors.'

One person told us 'I have recommended the practice to friends and family and now they all use the practice, it's because it's so friendly and you get treatment. I am impressed with the treatment' and 'I am very satisfied.'

All of the people we spoke to told us that their treatments options were explained to them and they had time to consider if they wanted to go ahead with the advice given to them by the dentist. We saw that records were detailed about the choices of treatments people had. They told us that appointments were made to suit them and they were seen quickly if they experienced any problems.

Staff were not supported in all areas. Formal, supervision did not take place. Staff were not sure of what to do in the event of possible signs of abuse and reporting this to the appropriate authority. Staff had not received recent training in safeguarding people and improvements are needed in this outcome.

There were systems in place to monitor how the practice was run, to ensure people receive a quality service.