Park Dental Studio Rotherham

We undertook a follow-up focused inspection of Park Dental Studio on 3 March 2020. 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 Park Dental Studio on 20 November 2020 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 regulations 12 and 17 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 Park Dental Studio on our website www.cqc.org.uk.

As part of this inspection we asked:

• Is it safe?

• Is it well-led?

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 breach we found at our inspection on 3 March 2020.

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 breach we found at our inspection on 3 March 2020.

Background

Park Dental Studio is in Rotherham and provides NHS and private treatment for adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice on local roads.

The dental team includes two dentists, two dental nurses and one receptionist. The practice has two treatment rooms.

The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.

During the inspection we spoke with the principal dentist, one dental nurse and the receptionist. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open: Monday to Thursday 9am – 5:30pm and Friday 9am – 4pm.

Our key findings were:

• Legionella management systems reflected published guidance.
• Systems were in place to manage sharps risks in line with current regulations.
• Systems were in place to ensure clinical staff had received appropriate vaccinations, including vaccination to protect them against the Hepatitis B virus.
• Infection prevention and control systems were in line with published guidance.
• The provider complied with guidance from the British Endodontic Society in respect to the use of dental dams.
• Fire safety systems reflected current regulations.
• The provider had introduced effective measures for sepsis awareness, identification and management.
• Prescription use was monitored and tracked in line with guidance.
• Systems were in place to manage patient safety alerts received from the Medicines and Healthcare products Regulatory Agency.
• Systems for the use of X-ray equipment complied with current regulations.

• Leadership, effective communication and oversight of clinical governance and management systems were improved.
• Systems to manage audit for quality assurance, learning and improvement were improved. One area required additional review.
• Systems to ensure effective oversight of the environmental cleaning standards were improved.
• The system in place to manage stock rotation was effective.

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

• Review the practice’s protocols to ensure audits of infection prevention and control are undertaken at regular intervals to ensure they reflect current systems in place.

We carried out this announced inspection on 20 November 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 Care Quality Commission, (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 this practice was not providing safe care in accordance with the relevant regulations.

Are services effective?

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

Are services caring?

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

Are services responsive?

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

Are services well-led?

We found this practice was not providing well-led care in accordance with the relevant regulations.

Background

Park Dental Studio is in Rotherham and provides NHS dental care and treatment for adults and children.

There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice.

The dental team includes two dentists, one dental nurse and one receptionist. The practice has two treatment rooms.

The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.

On the day of inspection, we collected 16 CQC comment cards filled in by patients. All comments reflected positively on the service provided.

During the inspection we spoke with the principal dentist, the dental nurse and the receptionist. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open: Monday to Thursday 9am – 5:30pm and Friday 9am – 4pm.

Our key findings were:

• The practice appeared to be visibly clean and well-maintained. Improvements could be made to monitor environmental cleaning processes.
• The practice’s infection control procedures did not reflect published guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
• Legionella management systems were not carried out in line with guidance.
• Improvement was needed to help them manage risk to patients and staff.
• The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The provider had staff recruitment procedures which reflected current legislation.
• 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 supported patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• Leadership and oversight could be improved to ensure guidance and regulations are being followed.
• Quality assurance systems could be improved to follow guidance and for learning and improvement.
• Staff felt involved and supported and worked 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 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.

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

• Take action to register the use of dental X-ray equipment with the Health and Safety Executive as required by Regulation from the 1 January 2018.
• 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.
• Review the security of the external waste receptacle to ensure it follows guidance issued in the Health Technical Memorandum 07-01.