Updated 31 August 2023
We carried out this announced comprehensive inspection on 8 August 2023 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 practice 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 advisor.
To get to the heart of patients’ experiences of care and treatment, we always ask the following 5 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:
- The dental clinic appeared clean and well-maintained.
- Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
- The practice had infection control procedures which mostly reflected published guidance.
- The practice had systems to manage risks for patients, staff, equipment and the premises.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The practice had staff recruitment procedures which reflected current legislation.
- Improvements could be made to monitor and track incoming and outgoing referrals.
- Clinical staff provided patients’ care and treatment in line with current guidelines.
- Patients were treated with dignity and respect. Staff took care to protect patients’ privacy and personal information.
- Staff provided preventive care and supported patients to ensure better oral health.
- The appointment system worked efficiently to respond to patients’ needs.
- The frequency of appointments was agreed between the dentist and the patient, giving due regard to National Institute of Health and Care Excellence (NICE) guidelines.
- There was effective leadership and a culture of continuous improvement.
- The level of detail recorded could be improved to ensure audits are fully effective.
- Staff felt involved, supported and worked as a team.
- Staff and patients were asked for feedback about the services provided.
- Complaints were dealt with positively and efficiently.
- The practice had information governance arrangements.
Background
Kimberworth Park Practice Limited is in Rotherham and provides NHS and private dental care and treatment for adults and children.
There is step free access to the practice for people who use wheelchairs and those with pushchairs. There is a free car park behind the practice and disability parking for a limited time directly outside of the practice.
The practice has made reasonable adjustments to support patients with access requirements.
The dental team includes 9 dentists, 3 foundation training dentists, 1 foundation training therapist, 12 dental nurses, 3 trainee dental nurses, 2 dental therapists, 1 practice manager and 2 receptionists. The practice has 8 treatment rooms.
During the inspection we spoke with 2 dentists, 1 foundation training dentist, 3 dental nurses, the foundation training therapist, 1 receptionist and the practice manager. We looked at practice policies, procedures and other records to assess how the service is managed.
The practice is open:
Monday and Tuesday from 8am to 6pm.
Wednesday to Friday from 8am to 5.30pm.
We noted innovative approaches to providing person centred care. For example, staff had placed a notice in the waiting room informing patients of the availability of a pictorial guide to the patient journey; available if a patient felt this would help them understand the dental treatment process more easily.
There were areas where the provider could make improvements. They should:
- Improve the practice’s infection control procedures and protocols taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’, in particular: the reprocessing of unbagged instruments, in-use materials remaining covered and use of the extractor fan in the decontamination room.
- Take action to improve the level of detail recorded in audits of radiography and antimicrobial prescribing. Practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.
- Implement a system to ensure patient referrals to other dental or health care professionals are centrally monitored to ensure they are received in a timely manner and not lost.