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Killamarsh Dental Practice - Killamarsh

Inspection Summary

Overall summary & rating

Updated 20 July 2021

We carried out this announced focussed inspection 15 June 2021 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 asked the following three questions:

• Is it safe?

• Is it effective?

• 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 well-led?

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


Killamarsh Dental Practice is in the village of Killamarsh on the outskirts of Sheffield and 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, including dedicated parking for people with disabilities, are available near the practice.

The dental team includes three dentists, one dental hygienist, four dental nurses and one receptionist. The practice has two treatment rooms, both are located on the ground floor.

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 Killamarsh Dental Practice is the practice manager.

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

The practice is open:

Monday: 9am to 4pm

Tuesday: 9am to 7pm

Wednesday and Thursday: 9am to 5pm

Friday: 8:30am to 3:30pm

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.
  • The provider had implemented standard operating procedures in line with national guidance on COVID-19.
  • The provider had 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.
  • The clinical staff provided patients’ care and treatment in line with current guidelines.
  • Staff had not had sepsis awareness training.
  • Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • The security of NHS prescription pads could be improved.
  • Staff provided preventive care and supported patients to ensure better oral health.
  • Improvements could be made to the audit system within the practice.
  • The provider had effective leadership and a culture of continuous improvement.
  • Staff felt involved and supported and worked as a team.

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

  • Improve the security of NHS prescription pads in the practice and ensure there are systems in place to track and monitor their use.

  • Take action to ensure that all staff have received training in sepsis awareness, and information is available for both staff and patients relating to sepsis.

  • Take action to ensure audits are undertaken to improve the quality of the service. The practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.

Inspection areas


No action required

Updated 20 July 2021

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

Safety systems and processes, including staff recruitment, equipment and premises and radiography (X-rays)

Staff had clear systems to keep patients safe.

Staff knew their responsibilities if they had concerns about the safety of children, young people and adults who were vulnerable due to their circumstances. The provider had safeguarding policies and procedures to provide staff with information about identifying, reporting and dealing with suspected abuse. We saw evidence that staff had received safeguarding training. Staff knew about the signs and symptoms of abuse and neglect and how to report concerns, including notification to the CQC. There was a designated lead person for safeguarding alerts within the practice. They had completed safeguarding training to the required level.

The provider had an infection prevention and control policy and procedures. They followed guidance in The Health Technical Memorandum 01-05: Decontamination in primary care dental practices, (HTM 01-05), published by the Department of Health and Social Care. Staff completed infection prevention and control training and received updates as required. There was a lead for infection control as recommended by the published guidance. The lead had undertaken infection control training in line with their continuing professional development and had the necessary training certificates in their file.

The provider had introduced procedures to minimise the risks to patients and staff related to COVID-19. These included reduced patient numbers, social distancing, personal protective equipment for staff, and face coverings for patients and any chaperones.

The provider had arrangements for transporting, cleaning, checking, sterilising and storing instruments in line with HTM 01-05. The records showed equipment used by staff for cleaning and sterilising instruments was validated, maintained and used in line with the manufacturers’ guidance.

The provider had suitable numbers of dental instruments available for the clinical staff and measures were in place to ensure they were decontaminated and sterilised appropriately.

We saw staff had procedures to reduce the possibility of Legionella or other bacteria developing in the water systems, in line with a risk assessment. All recommendations in the assessment had been actioned and records of hot and cold-water testing and dental unit water line management were maintained. The risk assessment had been completed by an external company in August 2018 and was kept under review internally on an annual basis.

We saw effective cleaning schedules to ensure the practice was kept clean. During the inspection we saw the practice was visibly clean.

The provider had policies and procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance. Measures were taken to ensure clinical waste was stored securely.

The infection control lead carried out infection prevention and control audits twice a year. The latest audit showed the practice was meeting the required standards.

The provider had a Speak-Up policy. Staff felt confident they could raise concerns without fear of recrimination.

The dentists used dental dam in line with guidance from the British Endodontic Society when providing root canal treatment. In instances where dental dam was not used, such as for example refusal by the patient, and where other methods were used to protect the airway, we saw this was documented in the dental care record and a risk assessment completed.

The provider had a recruitment policy and procedure to help them employ suitable staff and had checks in place for agency and locum staff. These reflected the relevant legislation. We looked at nine staff recruitment records. These showed the provider followed their recruitment procedure.

We observed that clinical staff were qualified and registered with the General Dental Council and had professional indemnity cover.

Staff ensured facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions, including electrical appliances.

A fire risk assessment was carried out in line with the legal requirements. We saw there were fire extinguishers and fire detection systems throughout the building and fire exits were kept clear.

The provider had a business continuity plan describing how they would deal with events that could disrupt the normal running of the practice.

The practice had arrangements to ensure the safety of the X-ray equipment and we saw the required radiation protection information was available.

We saw evidence the dentists justified, graded and reported on the radiographs they took. The provider carried out radiography audits every six months following current guidance and legislation. The provider had registered with the Health and Safety Executive in line with changes to legislation relating to radiography. Local rules for the X-ray units were available in line with the current regulations. The provider used digital X-rays. We noted neither X-ray machine was fitted with rectangular collimation. The provider told us action would be taken to address this.

Clinical staff completed continuing professional development in respect of dental radiography.

Risks to patients

The provider had implemented systems to assess, monitor and manage risks to patient safety.

The practice’s health and safety policies, procedures and risk assessments were reviewed regularly to help manage potential risk. The provider had current employer’s liability insurance.

A Covid-19 risk assessment had been completed. We observed staff were wearing personal protective equipment and a social distancing regime was in place.

We looked at the practice’s arrangements for safe dental care and treatment. The staff followed the relevant safety regulation when using needles and other sharp dental items.

The provider had a system in place to ensure clinical staff had received appropriate vaccinations, including vaccination to protect them against the Hepatitis B virus, and that the effectiveness of the vaccination was checked.

Staff were aware of sepsis but had not completed any formal training. We noted there were no sepsis prompts for staff or patient information posters displayed within the practice. This provider assured us this would be addressed.

Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

Emergency equipment and medicines were available as described in recognised guidance. However, we noted that buccal midazolam was not available. The provider told us there had been difficulties getting this from the pharmacy as stocks were low. As an alternative intravenous diazepam was available. We suggested the provider discuss this with their pharmacist as there could be more appropriate alternatives available. The provider assured us this would be addressed as soon as possible. We found staff kept records of their checks of these to make sure they were available, within their expiry date, and in working order.

A dental nurse worked with the dentists and dental hygienist when they treated patients in line with General Dental Council Standards for the Dental Team.

The provider had data information sheets and risk assessments related to substances that are hazardous to health. We noted this information was being updated at the time of this inspection and the systems and processes improved.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

We discussed with the dentists how information to deliver safe care and treatment was handled and recorded. We looked at dental care records with clinicians to confirm our findings and observed that individual records were typed and managed in a way that kept patients safe. Dental care records we saw were mostly complete and legible, kept securely and complied with General Data Protection Regulation requirements.

Medical histories were updated and were checked by the clinical staff at each visit.

Patient referrals to other service providers contained specific information which allowed appropriate and timely referrals in line with practice protocols and current guidance.

The provider had systems for referring patients with suspected oral cancer under the national two-week wait arrangements. These arrangements were initiated by National Institute for Health and Care Excellence to help make sure patients were seen quickly by a specialist.

Safe and appropriate use of medicines

The provider had systems for appropriate and safe handling of medicines.

There was a stock control system of medicines which were held on site. This ensured that medicines did not pass their expiry date and enough medicines were available if required.

The dentists were aware of current guidance with regards to prescribing medicines.

We saw the practice occasionally issued NHS prescriptions to patients. We noted there were no records of NHS prescriptions held in the practice as described in current guidance. The provider assured us a log would be introduced to give an audit trail and increase the security of prescription pads at the practice.

Antimicrobial prescribing audits were being completed, which was in line with Faculty of General Dental Practice (FGDP) guidelines.

Track record on safety, and lessons learned and improvements

The provider had implemented systems for reviewing and investigating when things went wrong. There were comprehensive risk assessments in relation to safety issues. Staff monitored and reviewed incidents. This helped staff to understand risks which led to effective risk management systems in the practice as well as safety improvements.

The practice had systems and processes to record, investigate and analyse any safety accidents or incidents that occurred. These systems were under review to better capture information and identify learning points.

The provider had a system for receiving and acting on safety alerts. Staff learned from external safety events as well as patient and medicine safety alerts. We saw they were shared with the team and acted upon if required. The practice reviewed regular Coronavirus (COVID-19) advisory information and alerts. Information was provided to staff and displayed for patients to enable staff to act on any suspected cases. Patients and visitors were requested to carry out hand hygiene and wear a mask on entering the premises. Information for patients relating to COVID-19 was available on the practice website. This included information about cleaning and safety regimes.


No action required

Updated 20 July 2021

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

Effective needs assessment, care and treatment

The practice had systems to keep dental practitioners up to date with current evidence-based practice. We saw that clinicians assessed patients’ needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

The practice’s systems included checks before and after treatment, emergency equipment requirements, medicines management, sedation equipment checks, and staff availability and training. They also included patient checks and information such as consent, monitoring during treatment, discharge and post-operative instructions.

Staff had access to digital X-rays to enhance the delivery of care. If access to an orthopantomogram (an X-ray of the whole mouth and jaws, rather than just one tooth) was required a referral would be made to the local dental hospital or a local practice who had this facility.

Helping patients to live healthier lives

The practice provided preventive care and supported patients to ensure better oral health in line with the Delivering Better Oral Health toolkit.

The dentists and dental hygiene therapist prescribed high concentration fluoride products if a patient’s risk of tooth decay indicated this would help them.

The dentists where applicable, discussed smoking, alcohol consumption and diet with patients during appointments.

Staff were aware of and involved with national oral health campaigns and local schemes which supported patients to live healthier lives, for example, local stop smoking services. They directed patients to these schemes when appropriate.

The dentists described the procedures they used to improve the outcomes for patients with gum disease. This involved providing patients with preventative advice, taking plaque and gum bleeding scores and recording detailed charts of the patient’s gum condition.

Consent to care and treatment

Staff obtained consent to care and treatment in line with legislation and guidance.

The practice team understood the importance of obtaining and recording patients’ consent to treatment. The staff were aware of the need to obtain proof of legal guardianship or Power of Attorney for patients who lacked capacity or for children who are looked after.

The dentists gave patients information about treatment options and the risks and benefits of these, so they could make informed decisions. We saw this documented in patients’ records. Patients confirmed their dentist listened to them and gave them clear information about their treatment.

The practice’s consent policy referred to Gillick competence, by which a child under the age of 16 years of age may give consent for themselves in certain circumstances. Staff were aware of the need to consider this when treating young people under 16 years of age. The team were aware of the Mental Capacity Act 2005 and understood their responsibilities under the act when treating adults who might not be able to make informed decisions. The best interest decisions section of the policy was updated during this inspection visit.

Staff described how they involved patients’ relatives or carers when appropriate and made sure they had enough time to explain treatment options clearly.

Monitoring care and treatment

The practice kept detailed dental care records containing information about the patients’ current dental needs, past treatment and medical histories. The dentist assessed patients’ treatment needs in line with recognised guidance. The relevant information was mostly recorded in a detailed and clear manner and was easily accessible for clinical staff. We saw some areas where improvements could be made and discussed these with the provider.

We saw that dental care records were being audited in line with national guidance. However, we also noted the audits had failed to identify the areas of improvement we saw and had discussed with the provider.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

Staff new to the practice had a structured induction programme. We confirmed clinical staff completed the continuing professional development required for their registration with the General Dental Council.

Co-ordinating care and treatment

Staff worked together and with other health and social care professionals to deliver effective care and treatment.

The dentists confirmed they referred patients to a range of specialists in primary and secondary care for treatment the practice did not provide. Staff monitored referrals through an electronic referral and tracking system to ensure they were responded to promptly.


Updated 20 July 2021


Updated 20 July 2021


No action required

Updated 20 July 2021

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

Leadership capacity and capability

We found leaders and managers had the capacity, values and skills to deliver high-quality, sustainable care.

The practice had undergone a change of ownership in the three months before this inspection. The new provider had undertaken a review of systems and processes and identified several areas where improvements were needed. The new provider was in the process of implementing an action plan to bring about improvements.

Leaders and managers were knowledgeable about issues and priorities relating to the quality and future of the service. They understood the challenges and were addressing them.

Leaders at all levels were visible and approachable. Staff told us they worked closely with them to make sure they prioritised compassionate and inclusive leadership. Staff told us they felt involved and their opinions were sought, this in turn made them feel valued and part of the team.

We saw the provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the practice. Further to this individual staff members had been given specific roles and responsibilities to encourage their learning and personal development.

The provider had a strategy for delivering the service which was in line with health and social priorities across the region. Staff planned the services to meet the needs of the practice population. The COVID-19 pandemic had reduced numbers of patients seen at the practice. However, the provider had taken steps to ensure the maximum number of patients who could receive an appointment, received one. Provided this could be done safely and giving due consideration to the restrictions imposed by COVID-19.


The practice had a culture of high-quality sustainable care.

Staff stated they felt respected, supported and valued. They were proud to work in the practice. Managers had systems to identify and act on behaviour and performance that was not consistent with the vision and values of the practice. These included a range of human resources policies and procedures.

Systems and processes had been introduced for all staff to have an annual appraisal. Discussions with the provider identified this would include personal development, a review of training needs and well-being. Due to the short time since the change of ownership, this had not yet been implemented, although everything was ready when needed.

Discussions with staff members identified they felt more involved since the change of ownership and told us their opinions and views had been actively sought by the new provider.

The provider had set up a virtual group which all staff could access through their mobile telephones. Staff told us this was a positive step forward and had improved communication between staff within the practice.

The staff focused on the needs of patients, the ground floor treatment rooms and level entry made accessing treatment for patients with mobility issues easy.

Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the Duty of Candour.

Staff could raise concerns and were encouraged to do so, and they had confidence that these would be addressed. Staff told us this was particularly so, since the change of ownership.

Governance and management

Staff had clear responsibilities, roles and systems of accountability to support good governance and management.

The provider and the registered manager had overall responsibilities for the management and clinical leadership of the practice. The provider oversaw the day to day running of the service. Staff knew the management arrangements and their roles and responsibilities.

The provider had a system of clinical governance in place which included policies, protocols and procedures that were accessible to all members of staff and were reviewed on a regular basis.

We saw there were clear and effective processes for managing risks, issues and performance.

Appropriate and accurate information

Staff acted on appropriate and accurate information.

Quality and operational information, for example surveys and audits were used to ensure and improve performance. Performance information was combined with the views of patients.

The provider had information governance arrangements and staff were aware of the importance of these in protecting patients’ personal information.

Engagement with patients, the public, staff and external partners

The practice involved patients, the public, staff and external partners to support high-quality sustainable services.

Patients were encouraged to complete the NHS Friends and Family Test (FFT). This is a national programme to allow patients to provide feedback on NHS services they have used. This had been suspended during the COVID-19 pandemic, so patients were encouraged to leave feedback on one of the on-line forums.

The practice gathered feedback from staff through meetings, surveys, and informal discussions. Staff were encouraged to offer suggestions for improvements to the service and said these were listened to and acted on.

Continuous improvement and innovation

The provider had systems and processes for learning, continuous improvement and innovation.

The provider had quality assurance processes to encourage learning and continuous improvement. These included audits of dental care records, radiographs and infection prevention and control. The provider had identified that improvements were needed to be made to the system of audits. An action plan was in place to improve the quality of audits within the practice so that improvements could be better identified and measured.

The provider showed a commitment to learning and improvement and valued the contributions made to the team by individual members of staff. There were systems in place to support staff in training and meeting the requirements of their continuing professional development.

Staff completed ‘highly recommended’ training as per General Dental Council professional standards. The provider supported and encouraged staff to complete continuing professional development.