Chesterfield Road Dental Practice

We undertook a focused inspection of Chesterfield Road Dental Practice on 7 August 2019. 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 Chesterfield Road Dental Practice on 11 February 2019 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 in breach of regulation 12, Safe care and treatment and 17, Good governance 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 Chesterfield Road Dental Practice on our website www.cqc.org.uk.

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 11 February 2019.

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 11 February 2019.

Background

Chesterfield Road Dental Practice is in Sheffield and provides mainly NHS and some private treatment to adults and children.

There is portable ramp access for people who use wheelchairs and those with pushchairs at the rear of the practice. Road side car parking spaces, are available near the practice.

The dental team includes six dentists, nine dental nurses (three of whom are trainees and one is the reception manager), two dental hygienists and a dedicated receptionist. The team are supported by a practice manager. The practice has four treatment rooms.

The practice is owned by an individual who is the practice owner. They 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 service also has a registered manager. The registered manager at Chesterfield Road Dental Practice is the practice manager.

During the inspection we spoke with two dental nurses and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Thursday 8:45am – 5:30pm

Friday 8:45am – 5pm.

Our key findings were:

• Infection control procedures reflected published guidance. Improvements had been made to bring processes fully in line with guidance and a lead person was appointed.
• Environmental and clinical cleaning standards were monitored visually but documented evidence of this was not kept.
• Legionella management, safer sharps management and sharps injury protocols were now better understood and were being managed effectively.
• Systems to manage medicines and life-saving equipment were improved and reflected recognised guidance.
• The practice had registered to receive patient safety alerts.
• Improvements had been made to the fire safety management systems.
• Clinical waste management systems were now effective and reflected recognised guidance.
• A process to monitor and track referrals had been implemented.
• Staff files were now kept secure.
• Improvements had been made to system for assessing materials and substances that are hazardous to health; further adjustments to the risk assessment process was required to ensure the process was effective.
• The practice had assessed the use and impact of the closed-circuit television with voice recording system.
• The system in place to monitor and track prescriptions required further action.
• A 5-year electrical fixed wiring safety check had taken place and recommendations were being acted upon.
• A process was now in place to ensure audits had action plans and the improvements can be demonstrated.
• Systems were in place to more effectively monitor and embed staff training.
• Leadership, teamwork and management had improved.

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

• Review the practice’s system for recording and monitoring environmental cleaning standards taking into account the guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices.
• Review the practice's policy for the control of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure appropriate risk assessments are undertaken.
• Review the security of NHS prescription pads in the practice and ensure there are systems in place to track and monitor their use.

We carried out this announced inspection on 11 February 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 not 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 not providing well-led care in accordance with the relevant regulations.

Background

Chesterfield Road Dental Practice is in Sheffield and provides mainly NHS and some private treatment to adults and children.

There is portable ramp access for people who use wheelchairs and those with pushchairs at the rear of the practice. Road side car parking spaces, are available near the practice.

The dental team includes six dentists, nine dental nurses (three of whom are trainees and one is the reception manager), two dental hygienists and a dedicated receptionist. The team are supported by a practice manager. The practice has four treatment rooms and two instrument decontamination facilities.

The practice is owned by an individual 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 Chesterfield Road Dental Practice is the practice manager.

On the day of inspection, we collected 34 CQC comment cards filled in by patients.

During the inspection we spoke with three dentists, three dental nurses, one dental hygienist and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Thursday 08:45 – 17:30

Friday 08:45 – 17:00

Our key findings were:

• The practice appeared clean and well maintained.
• Infection control procedures mostly reflected published guidance. Improvements could be made to bring processes fully in line with guidance.
• Systems to manage medicines and life-saving equipment could be improved.
• The practice had systems to help them manage risk to patients and staff, we identified that improvements could be made to the fire safety management systems, Legionella management and safer sharps management and injury protocols.
• The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The practice could not demonstrate that an electrical fixed wiring safety check had taken place since 2012.
• 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.
• The practice had a Closed-Circuit Television (CCTV) with voice recording system; its use and impact had not been assessed.
• Systems in place to monitor and track prescriptions and patient referrals were not consistent.
• Staff were providing preventive care and supporting patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• Leadership at the practice could be improved. Systems to monitor and embed staff training could be improved.
• 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.

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.