Abbeydale Road Family Dental Centre

We carried out this announced inspection on 29 January 2020 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 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

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 team was supported by the clinical quality and care manager during the inspection day. 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 Dental Practice is the clinical quality and care manager.

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

During the inspection we spoke with one dentist, two dental nurses, two receptionists and the clinical quality and care manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Friday 9am – 6pm.

Our key findings were:

• The practice appeared to be visibly clean and well-maintained.
• Improvement was needed to ensure infection control procedures reflected published guidance and the practice’s policy.
• Staff knew how to deal with emergencies. Appropriate medicines were available but not all life-saving equipment was in place.
• 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 awareness of responsibilities in respect to the Mental Capacity Act 2005 could be improved.
• The practice could improve and develop the practice's policies and procedures for obtaining patient consent.
• 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 of systems and processes could be improved to ensure guidance and regulations are being followed.
• Quality assurance systems were in place. Improvements could be made to the infection prevention and control audit process.
• 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:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulation the provider is not meeting are at the end of this report.

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

• Improve the practice's waste handling protocols to ensure waste is stored and disposed of in compliance with the relevant regulations, and taking into account the guidance issued in the Health Technical Memorandum 07-01.
• Implement an effective system for identifying, disposing and replenishing of out-of-date stock.
• Improve and develop the practice's policies and procedures for obtaining patient consent to care and treatment to ensure they are in compliance with legislation, take into account relevant guidance, and staff follow them.
• Improve and develop staff awareness of the requirements of the Mental Capacity Act 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.