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Inspection carried out on 4 February 2020

During a routine inspection

We carried out this announced inspection on 4 February 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 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

Churchview Dental Practice is in Doncaster and provides private dental care and treatment for adults and children. The practice also holds a small NHS children’s contract.

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 two dentists, two dental nurses, one dental hygiene therapist and two receptionists. The team is supported by the practice manager. The practice is visited on an ad-hoc basis by an implantologist and an implant trained dental nurse. The practice has two treatment rooms.

The practice is owned by an individual who is the principal dentist there. 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.

On the day of inspection, we collected 28 CQC comment cards filled in by patients. All comments reflected positively on the service provided.

During the inspection we spoke with the principal dentist, two dental nurses, one receptionist 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, Tuesday and Thursday 8:30am – 5:30pm.

Wednesday 8:30am – 12pm.

Friday 8:30am – 5pm.

Our key findings were:

  • The practice appeared to be visibly clean, tidy and well-maintained.
  • Improvement was needed to ensure infection control procedures reflected published guidance.
  • Staff knew how to deal with emergencies. Not all medicines and life-saving equipment were available.
  • Improvement was needed to managing risk to patients and staff, for example, safer sharps, risk assessment, NHS prescription management and response to patient safety alerts.
  • The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • The provider had staff recruitment procedures which reflected current legislation in most aspects. Disclosure and Barring Service checks were not risk assessed where appropriate.
  • Improvements could be made to ensure induction processes were in place for visiting staff.
  • 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.
  • Staff provided preventive care and supported patients to ensure better oral health.
  • The appointment system took account of patients’ needs.
  • Leadership and oversight of systems and processes could be improved.
  • The provider had systems to ensure continuous improvement; improvements could be made in this area.
  • 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 dealt with complaints positively and efficiently.
  • The provider had information governance arrangements.

We identified regulations the provider was not complying with. They must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulation the provider is not meeting are at the end of this report.

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

  • Take action to ensure sepsis awareness information and prompts for staff were visible to ensure early recognition, diagnosis and early management of sepsis.


Inspection carried out on 4 August 2016

During a routine inspection

We carried out an announced comprehensive inspection on 4 August 2016 to ask the practice the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

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

Background

Churchview Dental Practice is situated in Doncaster, South Yorkshire. It offers mainly private dental treatment to patients of all ages but also holds a small NHS contract for children. The services include preventative advice and treatment and routine restorative dental care.

The practice has two surgeries, a decontamination room, a waiting area and a reception area. All of the facilities are on the ground floor of the premises along with toilets.

There is one dentist, one dental hygiene therapist, two dental nurses (one of whom is a trainee), one receptionists and a practice manager.

The opening hours are Monday, Tuesday, Thursday and Friday from 8-00am to 5-30pm, Wednesday from 8-00am to 12-30pm and Saturday by appointment only.

The principal dentist is registered with the Care Quality Commission (CQC) as an individual. 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.

During the inspection we spoke with five patients who used the service and reviewed 65 completed CQC comment cards. The patients were positive about the care and treatment they received at the practice. Comments included that the practice had a very caring ethos and that staff were helpful and friendly and supportive. They also commented that the practice was always clean and hygienic and the dentist explained treatments clearly.

Our key findings were:

  • The practice was visibly clean and uncluttered.
  • The practice had systems in place to assess and manage risks to patients and staff including health and safety and the management of medical emergencies.
  • Staff were qualified and had received training appropriate to their roles.
  • Patients were involved in making decisions about their treatment and were given clear explanations about their proposed treatment including costs, benefits and risks.
  • The dentist was passionate about providing the best care for patients.
  • Oral health advice and treatment were provided in-line with the ‘Delivering Better Oral Health’ toolkit (DBOH).
  • We observed that patients were treated with kindness and respect by staff.
  • There was a warm and welcoming feel to the practice.
  • Staff ensured there was sufficient time to explain fully the care and treatment they were providing in a way patients understood.
  • The practice had a complaints system in place and there was an openness and transparency in how these were dealt with.
  • Patients were able to make routine and emergency appointments when needed.
  • The governance systems were effective.

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

  • Review the current legionella risk assessment and implement the required actions including the monitoring and recording of water temperatures, giving due regard to the guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and the Health and Safety Executive –Approved Code of Practice L8: Legionnaires’ disease “The control of legionella bacteria in water systems”.

Inspection carried out on 19 October 2012

During a routine inspection

We spoke with three people who used the service. They spoke positively about the care and treatment they had received. They told us they were provided with sufficient information to make a decision about their treatment. One person told us: �Excellent service, I get good information. The dentist always discusses options and costs prior to my treatment.� Another person said: �I am highly satisfied with the care and treatment.�

Evidence showed people were protected from the risk of infection because appropriate guidance had been followed. People we spoke with told us the surgery was very clean and staff always wore protective clothing when treating them.

Staff received appropriate professional development. A training programme was in place to provide staff with the training and support they needed to maintain their qualifications. People we spoke with told us staff were always polite and respectful and provided a good standard of care.

The dental practice had an effective system to regularly assess and monitor the quality of service that people received. There was evidence learning from incidents and investigations took place and appropriate changes were implemented. The practice had a complaints policy and took account of complaints and comments to improve the service