Updated 31 January 2020
We undertook a follow up desk-based inspection of Percival and Burnham Dental Surgery on 30 December 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 had remote access to a specialist dental adviser.
We undertook a comprehensive inspection of Percival and Burnham Dental Surgery on 29 October 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 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 Percival and Burnham Dental Surgery 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 breach we found at our inspection on 30 December 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 breach we found at our inspection on 30 December 2019.
Background
Percival and Burnham Dental Surgery is in Sheffield and provides mainly NHS care and treatment for adults and children.
There is ramp access from the pavement to the practice, where there is a single step to enter the practice. A portable ramp is available to assist people who use wheelchairs and those with pushchairs. Car parking spaces available near the practice on local roads.
The dental team includes three dentists, five dental nurses (two of whom are trainees), one dedicated receptionist who is also an assistant manager and two practice managers. 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.
During the inspection we spoke with the practice manager. We reviewed practice policies and procedures and other records about how the service is managed.
The practice is open: Monday – Friday 8:30am – 6pm
Our key findings were:
- Legionella management systems were in line with recommended guidance.
- A risk mitigation system was place for staff waiting for confirmation of Hepatitis B vaccination effectiveness.
- Fire safety management systems were managed in line with current regulations.
- Safer sharps systems were in line with current regulations.
- Sepsis awareness systems were in place and were embedded.
- Risk assessments for the use of materials that are hazardous to health were in place.
- A system was in place to respond to patient safety alerts.
- Learning and continuous improvement from audits was effective.
- The practice now complied with guidance relating to the completion of dental care records.
- The practice now complied with guidance relating to the frequency to take radiographs.
- Dental care records were kept securely in line with current regulations.