Updated 13 April 2023
We carried out this announced comprehensive inspection on 13 March 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, the following 5 questions were asked:
- 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 recently introduced systems to manage risks for patients, staff, equipment, and the premises.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The practice had staff recruitment procedures which mostly reflected current legislation. Protocols were introduced to obtain existing staff employment records.
- 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 dentist and the patient, giving due regard to National Institute of Health and Care Excellence (NICE) guidelines.
- There was effective leadership and a culture of continuous improvement. Systems to ensure good governance were ongoing.
- Staff felt involved, supported, and worked as a team.
- Systems were ongoing to embed new and existing processes after a period of staffing instability.
- Systems were ongoing to ensure staff knew how to act on patient safety alerts and incident reporting.
- 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
Pitsmoor Dental Health Centre is in Sheffield and provides NHS and private dental care and treatment for adults and children.
There is step free access at the rear of the practice for people who use wheelchairs and those with pushchairs. Limited car parking spaces are available at the practice. The practice has made reasonable adjustments to support patients with access requirements.
The dental team includes 2 dentists, 3 dental nurses, a dedicated decontamination dental nurse, a practice manager, and a receptionist. The practice has 4 treatment rooms.
During the inspection we spoke with 2 dentists, 3 dental nurses, the receptionist, 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 to Thursday 9am – 5.30pm and Friday 9am – 2pm.
There were areas where the provider could make improvements. They should:
- Improve the practice's recruitment policy and procedures to ensure accurate, complete, and detailed records are maintained for all staff.
- Improve the practice's processes for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken and the products are stored securely.
- Implement practice protocols and procedures to ensure staff are up to date with their mandatory training and their continuing professional development.
- Ensure an effective system is in place for receiving and responding to patient safety alerts and the recording, investigating, and reviewing incidents or significant events.