Updated 13 October 2021
We carried out this announced focussed inspection on 21 September 2021 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 three questions:
• Is it safe?
• Is it effective?
• 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 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 well-led?
We found this practice was providing well-led care in accordance with the relevant regulations.
Background
Peasholm Dental Practice is in Scarborough and provides NHS and private 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 six dentists, seven dental nurses, two dental hygienists, three dental hygiene therapists and two dedicated receptionists. The team is supported by the practice manager. The practice has nine treatment rooms.
The practice is owned by a company and as a condition of registration must have a person registered with the CQC 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 Peasholm Dental Practice is the principal dentist.
During the inspection we spoke with three dentists, three dental nurses, three receptionists 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 8:30am – 5:30pm and Friday 8:30am – 5pm.
Our key findings were:
- The practice appeared to be visibly clean and well-maintained.
- The provider had infection control procedures which reflected published guidance.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- The provider had systems to help them manage risk to patients and staff; the risks of using substances that are hazardous to health had not been assessed.
- The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- Systems to monitor and track prescription use could be improved.
- 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 awareness of Gillick competency could be improved.
- Staff provided preventive care and supported patients to ensure better oral health.
- The appointment system took account of patients’ needs.
- The provider had effective leadership and a culture of continuous 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.
There were areas where the provider could make improvements. They should:
- 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.
- Improve systems in the practice to ensure NHS prescription pads are monitored and tracked.
- Review staff awareness of Gillick competency and ensure all staff are aware of their responsibilities in relation to this.