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Inspection Summary


Overall summary & rating

Updated 2 September 2019

We undertook a focused inspection of Chesterfield Road Dental Practice on 7 August 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 was supported by a specialist dental adviser.

We undertook a comprehensive inspection of Chesterfield Road Dental Practice on 11 February 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 regulation 12, Safe care and treatment and 17, Good governance 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 Chesterfield Road Dental Practice 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 breaches we found at our inspection on 11 February 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 breaches we found at our inspection on 11 February 2019.

Background

Chesterfield Road Dental Practice is in Sheffield and provides mainly NHS and some private treatment to adults and children.

There is portable ramp access for people who use wheelchairs and those with pushchairs at the rear of the practice. Road side car parking spaces, are available near the practice.

The dental team includes six dentists, nine dental nurses (three of whom are trainees and one is the reception manager), two dental hygienists and a dedicated receptionist. The team are supported by a practice manager. The practice has four 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 Chesterfield Road Dental Practice is the practice manager.

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

The practice is open:

Monday to Thursday 8:45am – 5:30pm

Friday 8:45am – 5pm.

Our key findings were:

  • Infection control procedures reflected published guidance. Improvements had been made to bring processes fully in line with guidance and a lead person was appointed.
  • Environmental and clinical cleaning standards were monitored visually but documented evidence of this was not kept.
  • Legionella management, safer sharps management and sharps injury protocols were now better understood and were being managed effectively.
  • Systems to manage medicines and life-saving equipment were improved and reflected recognised guidance.
  • The practice had registered to receive patient safety alerts.
  • Improvements had been made to the fire safety management systems.
  • Clinical waste management systems were now effective and reflected recognised guidance.
  • A process to monitor and track referrals had been implemented.
  • Staff files were now kept secure.
  • Improvements had been made to system for assessing materials and substances that are hazardous to health; further adjustments to the risk assessment process was required to ensure the process was effective.
  • The practice had assessed the use and impact of the closed-circuit television with voice recording system.
  • The system in place to monitor and track prescriptions required further action.
  • A 5-year electrical fixed wiring safety check had taken place and recommendations were being acted upon.
  • A process was now in place to ensure audits had action plans and the improvements can be demonstrated.
  • Systems were in place to more effectively monitor and embed staff training.
  • Leadership, teamwork and management had improved.

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

  • Review the practice’s system for recording and monitoring environmental cleaning standards taking into account the guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices.
  • Review the practice's policy for the control of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure appropriate risk assessments are undertaken.
  • Review the security of NHS prescription pads in the practice and ensure there are systems in place to track and monitor their use.
Inspection areas

Safe

No action required

Updated 2 September 2019


Effective

No action required

Updated 22 March 2019

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

The dentists assessed patients’ needs and provided care and treatment in line with recognised guidance. Patients described the treatment they received as excellent, caring and professional. The dentists discussed treatment with patients so they could give informed consent and recorded this in their records.

The practice had arrangements to refer patients to other dental or health care professionals. Systems to monitor and track patient referrals including fast track referrals were inconsistent.

The provider supported staff to complete training relevant to their roles; systems to help monitor these were ineffective. We identified staff knowledge gaps, including, IPC, audit completion, Legionella processes, sharps injury procedures and the location of some medical emergency equipment.

Caring

No action required

Updated 22 March 2019

We found that this practice was providing caring services in accordance with the relevant regulations.

We received feedback about the practice from 34 people. Patients were positive about all aspects of the service the practice provided. They told us staff were friendly and efficient.

They said that they were given helpful, honest explanations about dental treatment, and said their dentist listened to them. Patients commented that they made them feel at ease, especially when they were anxious about visiting the dentist.

We saw that staff protected patients’ privacy and were aware of the importance of confidentiality. Patients said staff treated them with dignity and respect.

The practice had a CCTV with voice recording system; no Privacy Impact Assessment was in place to consider and justify its use.

Responsive

No action required

Updated 22 March 2019

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

The practice’s appointment system took account of patients’ needs. Patients could get an appointment quickly if in pain.

Staff considered patients’ different needs. This included providing facilities for patients with a disability and families with children. The practice had access to telephone interpreter services and had arrangements to help patients with sight or hearing loss.

The practice took patients views seriously. They valued compliments from patients and responded to concerns and complaints quickly and constructively.

Well-led

No action required

Updated 2 September 2019