Updated 21 January 2021
We undertook a follow up desk-based review of Abbeydale Road Family Dental Practice on 29 December 2020. This review 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 review was led by a CQC inspector who had access to a specialist dental adviser.
We undertook a comprehensive inspection of Abbeydale Road Family Dental Practice on 29 January 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 well led care and was in breach of regulation 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 Abbeydale Road Family Dental Practice on our website www.cqc.org.uk.
As part of this desk-based review, we reviewed the provider’s action plan and evidence submitted to us. The practice had identified where there was a shortfall and had actions in place to ensure the practice was providing well-led care in accordance with the relevant regulations.
Our findings were:
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 review on 29 December 2020.
Background
Abbeydale Road Dental Practice is in Sheffield and provides mainly 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 on local roads.
The dental team includes three dentists, four dental nurses and two receptionists. The practice has five treatment rooms.
The practice is owned by a partnership 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 Abbeydale Road Dental Practice is the clinical quality and care manager.
The practice is open:
Monday to Friday 9am – 6pm.
Our key findings were:
- Oversight of the practice’s hot water system in respect to Legionella management and health and safety was effective.
- Infection prevention and control (IPC) procedures followed guidance in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, (HTM 01-05), published by the Department of Health and Social Care.
- Emergency lighting was installed at the practice to comply with current fire regulations.
- Safer sharps systems were brought in line with current regulations.
- Oversight and management of the medical emergency kit was revised to reflect current guidance.
- Systems to identify, record and investigate significant incidents and events were reviewed to ensure they were embedded.
- The provider reviewed the staff rotation and induction processes to ensure up-to-date, on-site information is available to reduce the risks associated with rotating staff throughout the organisation.
- The practice reviewed its waste handling protocols to ensure waste is stored and disposed of in compliance with the relevant regulations.
- An effective system was implemented to identify, dispose and replenish of out-of-date stock.
- The provider updated policies and procedures for obtaining patient consent to care and treatment to ensure the practice was compliant with legislation and guidance.
- Systems were put in place to ensure staff were aware of the requirements and responsibilities associated with the Mental Capacity Act 2005.