Updated 16 February 2023
We carried out this announced comprehensive inspection on 17 January 2023 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 practice 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 advisor.
To get to the heart of patients’ experiences of care and treatment, we always ask the following 5 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:
- The dental clinic appeared clean and well-maintained.
- The practice had infection control procedures which reflected published guidance.
- Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
- The practice had systems to manage risks for patients, staff, equipment and the premises.
- Improvements could be made to ensure sharps safety and prescription management reflected current guidance and legislation.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The practice had staff recruitment procedures which reflected current legislation.
- Clinical staff provided patients’ care and treatment in line with current guidelines.
- Patients were treated with dignity and respect. Staff took care to protect patients’ privacy and personal information.
- Staff provided preventive care and supported patients to ensure better oral health.
- The appointment system worked efficiently to respond to patients’ needs.
- The frequency of appointments was agreed between the orthodontist and the patient, giving due regard to British Orthodontic Society.
- There was effective leadership and a culture of continuous improvement. A review of current audit processes would be beneficial.
- Staff felt involved, supported and worked as a team.
- Staff and patients were asked for feedback about the services provided.
- Complaints were dealt with positively and efficiently.
- The practice had information governance arrangements.
Background
Crystal Peaks Orthodontic Centre is in Sheffield and provides NHS and private orthodontic dental care and treatment for adults and children.
The orthodontic practice is based in a multidisciplinary medical facility on the 1st floor. There is step free access to the ground floor and a lift to the orthodontic practice ensuring patients with limited mobility, wheelchairs and those with pushchairs can access the practice. Car parking spaces, including dedicated parking for disabled people are available outside the practice. The practice has made reasonable adjustments to support patients with access requirements.
The dental team includes 4 orthodontists, 2 orthodontic therapists, 6 dental nurses (2 of whom cover reception) and a practice manager. The practice has 2 orthodontic treatment areas.
During the inspection we spoke with 2 orthodontists, 3 dental nurses and the practice manager. We looked at practice policies, procedures and other records to assess how the service is managed.
The practice is open: Monday and Tuesday 8:30am to 6:30pm, Wednesday, Thursday and Friday 8:30am to 5pm and alternate Saturdays 10am to 2pm.
The practice had taken steps to improve environmental sustainability. For example, the orthodontic practice shared dental facilities and maintenance contracts with the general dental practice located on the same floor; medical emergency equipment, decontamination equipment and X-ray units were jointly used. Staff rooms and dental treatment rooms were also available to both departments, this helped limit equipment and materials duplication and lower energy usage.
There were areas where the provider could make improvements. They should:
- Improve the practice’s sharps procedures to ensure the practice is in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
- Review the process of pre-stamping NHS prescription pads.
- Improve the practice protocols regarding auditing patient care records to check that necessary information is recorded. In addition, ensure clinical audits are completed specific to each clinician.