Archived: Percival and Burnham Dental Surgery

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.

We carried out this announced inspection on 29 October 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 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

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.

On the day of inspection, we collected 36 CQC comment cards filled in by patients. All comments were positive about the service being provided.

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

The practice is open: Monday to Friday 8:30am to 6pm

Our key findings were:

• The practice appeared to be visibly clean and well-maintained.
• 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 current systems to help them manage risk to patients and staff.
• 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.
• Except for two areas where further learning was required, clinical staff provided patients’ care and treatment in line with current guidelines.
• The level of detail recorded in dental care records could be improved.
• 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.
• Improvements could be made to management and oversight of clinical governance.
• Systems for reviewing audit and responding to action plans could be improved.
• 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 security of patient dental care records could be improved.
• 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.