Archived: Alex Jones Dentistry Penistone

We carried out this announced inspection on 16 July 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 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

Penistone Dental Care is in Penistone, Sheffield and provides private treatment to adults and children. Parking is available outside the practice and locally in public car parks.

There is step access into the practice which can limit entry for people who use wheelchairs and those with pushchairs. Patients are referred to the sister practice if ramp access is required.

The dental team includes the principal dentist and an associate dentist, four dental nurses (one of whom is the lead dental nurse and one is the patient care co-ordinator), two dental hygiene therapists, a receptionist and a practice manager. The practice is also visited on an ad-hoc basis by a sedationist and an implant dentist. The practice has two treatment rooms.

The practice is owned by a company 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 Penistone Dental Care Limited is the principal dentist.

On the day of inspection, we collected 10 CQC comment cards filled in by patients. All comments reflected positively on the service provided.

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

The practice is open:

Our key findings were:

• The practice appeared clean and well maintained.
• The provider had infection control procedures which reflected published guidance in most respects. There were some areas where improvements could be made.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
• The provider had systems to help them manage risk to patients and staff.
• Local rules for radiography required updating.
• The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• 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.
• Staff provided preventive care and supporting patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• The provider had effective leadership.
• The practice had a culture of continuous improvement, adjustments could be made to improve this.
• Staff felt involved and supported and worked well 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 suitable information governance arrangements.

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

• Review the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment. In particular, ensure the local rules for radiography are in compliance with the regulation.
• Review the practice’s infection control procedures and protocols taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’. In particular, review the equipment and materials used in the treatment room to ensure they are used/kept in line with guidance. Also ensure data downloaded from the autoclave is reviewed and actioned accordingly.
• Review the practice’s protocols to ensure audits of infection prevention and control accurately reflect the practice’s processes. The practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.