• Dentist
  • Dentist

South Elmsall Family Dental Centre

51 Barnsley Road, South Elmsall, Pontefract, West Yorkshire, WF9 2RN (0115) 979 0909

Provided and run by:
Nationwide Healthcare

All Inspections

22 September 2020

During an inspection looking at part of the service

We undertook a follow up focused inspection of South Elmsall Family Dental Centre on 22 September 2020. This inspection was carried out to review in detail 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 adviser.

We undertook a comprehensive inspection of South Elmsall Family Dental Centre on 29 January 2020 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 and 17 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 South Elmsall Family Dental Centre on our website .

As part of this inspection we asked:

•Is it safe?

•Is it well-led?

When one or more of the five questions are not met we require the service to make improvements and send us an action plan. We then inspect again after a reasonable interval, focusing on the areas where improvement was required.

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 29 January 2020.

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 29 January 2020.

Background

South Elmsall Family Dental Centre provides NHS and private dental care and treatment for adults and children.

There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice.

The dental team includes six dentists, six dental nurses (three of who are trainees) and five receptionists. The practice has six treatment rooms.

The practice is owned by a company and as a condition of registration must have a person registered with the CQC 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 South Elmsall Family Dental Centre is the Clinical Quality and Care Manager.

During the inspection we spoke with two dentists, one dental nurse and the Clinical Quality and Care Manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Friday from 9:00am to 6:00pm

Our key findings were :

  • Action had been taken to ensure the fire alarm and emergency lighting had been serviced. A fixed wire installation test had been carried out.
  • Action had been taken to ensure water temperatures reached the recommended temperature to reduce the risks associated with Legionella.
  • Recommendations made in the routine and critical examinations for the X-ray machines had been actioned.
  • Antibacterial prescribing had been reviewed and was being audited.
  • Audits of radiography and disability access had been carried out.
  • Systems and processes to manage the risks associated with the carrying out of the regulated activities had been implemented to ensure good governance in the long term.

29 January 2020

During a routine inspection

We carried out this announced inspection on 29 January 2020 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 Care Quality Commission, (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 this practice was not providing safe care in accordance with the relevant regulations.

Are services effective?

We found this practice was providing effective care in accordance with the relevant regulations.

Are services caring?

We found this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found this practice was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found this practice was not providing well-led care in accordance with the relevant regulations.

Background

South Elmsall Family Dental Centre provides NHS and private dental care and treatment for adults and children.

There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice.

The dental team includes six dentists, five dental nurses and four receptionists. The practice has six treatment rooms.

The practice is owned by a company and as a condition of registration must have a person registered with the CQC 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 South Elmsall Family Dental Centre is the Clinical Quality and Care Manager.

On the day of inspection, we collected one CQC comment card filled in by a patient.

During the inspection we spoke with three dentists, two dental nurses, two receptionists, the group head nurse and group deputy head nurse. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Friday from 9:00am to 6:00pm

Our key findings were:

  • The practice appeared to be visibly clean.
  • 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.
  • Improvements could be made to the process for managing the risks associated with the carrying out of the regulated activities.
  • The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • Current guidelines for prescribing antibiotics were not always adhered to.
  • 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.
  • Clinical leadership and oversight of arrangements for managing risk were not effective.
  • Staff felt involved and supported and worked as a team.
  • The provider asked staff and patients for feedback about the services they provided.
  • The provider had information governance arrangements.

We identified regulations the provider was not complying with. 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.

Full details of the regulations the provider was not meeting are at the end of this report.