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Inspection Summary


Overall summary & rating

Updated 22 March 2019

We carried out this announced inspection on 11 February 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 not 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 not providing well-led care in accordance with the relevant regulations.

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 and two instrument decontamination facilities.

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.

On the day of inspection, we collected 34 CQC comment cards filled in by patients.

During the inspection we spoke with three dentists, three dental nurses, one dental hygienist 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 08:45 – 17:30

Friday 08:45 – 17:00

Our key findings were:

  • The practice appeared clean and well maintained.
  • Infection control procedures mostly reflected published guidance. Improvements could be made to bring processes fully in line with guidance.
  • Systems to manage medicines and life-saving equipment could be improved.
  • The practice had systems to help them manage risk to patients and staff, we identified that improvements could be made to the fire safety management systems, Legionella management and safer sharps management and injury protocols.
  • The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • The practice could not demonstrate that an electrical fixed wiring safety check had taken place since 2012.
  • 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.
  • The practice had a Closed-Circuit Television (CCTV) with voice recording system; its use and impact had not been assessed.
  • Systems in place to monitor and track prescriptions and patient referrals were not consistent.
  • Staff were providing preventive care and supporting patients to ensure better oral health.
  • The appointment system took account of patients’ needs.
  • Leadership at the practice could be improved. Systems to monitor and embed staff training could be improved.
  • 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.

We identified regulations the provider was not complying with. They must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulations the provider was not meeting are at the end of this report.

Inspection areas

Safe

Improvements required

Updated 22 March 2019

We found that this practice was not providing safe care in accordance with the relevant regulations. We have told the provider to take action (see full details of this action in the Requirement Notices section at the end of this report).

The practice had systems and processes to provide safe care and treatment. They used learning from incidents and complaints to help them improve.

Staff received training in safeguarding people and knew how to recognise the signs of abuse and how to report concerns.

Staff were qualified for their roles and the practice completed essential recruitment checks.

The practice had system to help them manage risk. We identified where improvements could be made to fire safety management systems, Legionella management, safer sharps management and injury protocols and clinical waste security and disposal.

Premises and equipment were clean and properly maintained.

An in-date electrical fixed wiring safety check was not available on the inspection day. The only certificate available to review was dated 2012.

The practice had an infection prevention and control (IPC) policy. Some areas of the IPC process were not carried out in line with recommended guidance and we identified some staff knowledge gaps. The ground floor room used for the decontamination and processing of dental instruments was ill-equipped and did not reflect recommended guidance.

The practice carried out infection prevention and control audits bi-annually. The completion of these audits could be more closely monitored to ensure areas of non-compliance are highlighted and addressed.

There was a historical system for receiving and acting on safety alerts but no recorded evidence since 2017.

There was no process in place to monitor and track issued prescriptions

The emergency medical kit was not managed in line with recommended guidance. We identified some areas where improvements could be made.

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

Improvements required

Updated 22 March 2019

We found that this practice was not providing well-led care in accordance with the relevant regulations. We have told the provider to take action (see full details of this action in the Requirement Notices section at the end of this report).

The provider was not present during the inspection day. We identified some systems and processes had failed to be maintained effectively since the last CQC inspection visit in 2016. The registered manager explained there had been a prolonged period of instability which had resulted in staff shortages, training and recruitment issues which had impacted on the productivity and management of the practice. They gave assurance that improvements would be made to address the areas identified during feedback.

We found the dentists and dental hygienists had the capacity and skills to deliver high-quality, sustainable care.

There were systems of clinical governance in place which included policies, protocols and procedures. We found some processes supporting these were not fully understood and were not always carried out correctly or effectively monitored to ensure the practice was performing in accordance with recommended guidance and legislation. For example:

  • Infection prevention and control processes were not always carried out in line with recommended guidance.
  • Legionella management systems were not managed effectively and some processes were not embedded.
  • Systems in place to manage the medical emergency kit were not embedded.
  • Systems in place to manage safer sharps procedures were not consistent.

There were processes for managing risks but these required embedding and updating to reflect the practice procedures. For example:

  • The sharps risk assessment did not reflect the varying processes carried out at the practice.
  • A full review of the risks associated with materials identified under COSHH had not taken place.
  • A system to ensure fixed electrical wiring re-certification was carried out at timely intervals was not in place.

The practice team kept complete patient dental care records which were stored securely.

The practice used patient surveys to obtain staff and patients’ views about the service. We saw examples of suggestions from patients the practice had acted on.

We noted that not all staff had received a recent appraisal. We reviewed records for those who had and saw they discussed learning needs, general wellbeing and aims for future professional development. There was a plan in place to address the remaining appraisals.

The practice’s quality assurance and audit processes could be improved to ensure data was gathered and recorded accurately to encourage suitable outcomes, learning and continuous improvement.