The Care Quality Commission
  • Dentist
  • Dentist

Yorkshire Dental Suite

347 Oakwood Lane, Leeds, West Yorkshire, LS8 3HA (0113) 887 9594

Provided and run by:
Mr Abdulbaset Dalghous

All Inspections

06/12/2021

During an inspection looking at part of the service

We undertook a follow-up focused inspection of Yorkshire Dental Suite on 6 December 2021. 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 two specialist dental advisers.

We undertook a comprehensive inspection of Yorkshire Dental Suite on 31 August 2021 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 Regulations 17 and 18 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 Yorkshire Dental Suite on our website www.cqc.org.uk.

As part of this inspection we asked:

• Is it well-led?

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 breaches we found at our inspection on 31 August 2021.

Background

Yorkshire Dental Suite is in Leeds and provides 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 at the practice.

The dental team includes five dentists, one dental hygienist and six dental nurses who also cover reception duties. The practice has five treatment rooms and the team is supported by an operations manager.

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 provider, the operations manager, the dental hygienist and a dental nurse. We looked at practice policies and procedures and other records about how the service is managed.

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.

The practice is open:

Monday, Thursday and Friday 9am to 5pm

Tuesday and Wednesday 9am to 6pm

Saturday 9am to 3pm

Our key findings were:

  • Systems for recording, investigating and reviewing incidents or significant events were in place.
  • Additional training had taken place to ensure infection prevention and control processes were in line with published guidance. We identified areas still in need of improvement.
  • Safer sharps systems and processes were in line with current guidance and regulations.
  • Systems to ensure the equipment in the medical emergency kit remained in date were improved.
  • Systems to mitigate role-related risks to protect staff members were in place.
  • Improvements had been made to ensure effective oversight of governance and compliance to support the team.
  • Documents which were unavailable at the previous inspection were available, reviewed and found to be in order.
  • Staff training records and certification which were unavailable at the previous inspection relating to the delivery of conscious sedation were available, were reviewed and found to be in order.
  • Systems were in place to record role-related continuing professional development for staff. The system was in its early stages of use and required embedding within the team.

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, effective use of the light magnification to identify debris on instruments prior to sterilisation and the sessional change of solution in the ultrasonic bath.
  • Implement and embed practice protocols and procedures to ensure staff remain up to date with their mandatory training and their continuing professional development.

31 August 2021

During an inspection looking at part of the service

We carried out this announced focused inspection on 31 August 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 not providing well-led care in accordance with the relevant regulations.

Background

Yorkshire Dental Suite is in Leeds and provides 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 at the practice.

The dental team includes five dentists, one dental hygienist and six dental nurses who also cover reception duties. The practice has five treatment rooms and the team is supported by an operations manager.

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 two dentists, one dental nurse, the dental hygienist and the reception, front of house staff. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday, Thursday and Friday 9am to 5pm

Tuesday and Wednesday 9am to 6pm

Saturday 9am to 3pm

Our key findings were:

  • The practice appeared to be visibly clean and well-maintained.
  • Infection control procedures did not reflect published guidance.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available; some medical equipment had passed its expiry date.
  • The provider had systems to help them manage risk to patients and staff, some of which required review.
  • The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • Systems to evidence role specific staff training and certification were not effective.
  • The provider had no system in place for reviewing and investigating when things went wrong.
  • The provider had staff recruitment procedures which reflected current legislation.
  • The clinical staff provided patients’ care and treatment in line with current guidelines.
  • Improvements could be made to ensure clinicians remained up to date with evidenced-based practice.
  • Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • The practice referral process could be improved.
  • Staff provided preventive care and supported patients to ensure better oral health.
  • The appointment system took account of patients’ needs.
  • Improvements could be made to ensure oversight and management of systems and processes was effective.
  • The practice culture of continuous improvement would benefit from effective auditing.
  • 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.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

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:

  • Implement audits for patient dental care records to check that necessary information is recorded and audits for prescribing of antibiotic medicines taking into account the guidance provided by the Faculty of General Dental Practice.
  • Implement a system to ensure patient referrals to other dental or health care professionals are clearly prescribed and monitored to ensure they are received in a timely manner and not lost.
  • Take action to ensure the clinicians remain up to date with evidenced based practice, in particular; delivering better oral health, National Institute for Health and Care Excellence (NICE) guidance and The Mental Capacity Act 2005.

26 June 2017

During a routine inspection

We carried out this announced inspection on 26 June 2017 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 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 that this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

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

Are services caring?

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

Are services responsive?

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

Are services well-led?

We found that this practice was providing well-led care in accordance with the relevant regulations.

Background

Yorkshire Dental Suite is in Leeds and provides private treatment to adults and children. Services include dental implants, conscious sedation and minor oral surgery.

There is level access for people who use wheelchairs and pushchairs. The practice has a dedicated car park which includes one space for disabled badge holders.

The dental team includes five dentists, one dental hygienist and therapist, two dental nurses and a locum dental nurse. The dental nurses also cover reception duties. The practice has two treatment rooms, a recovery room, a decontamination room and an X-ray room.

The practice is owned by an individual who is the principal dentist. 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 46 CQC comment cards filled in by patients. This information gave us a positive view of the practice.

During the inspection we spoke with two dentists and two dental nurses. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday and Friday from 9:00am to 6:00pm

Tuesday and Thursday from 8:00am to 5:30pm

Wednesday from 9:00am to 8:00pm

Saturday – by appointment only

Our key findings were:

  • The practice was clean and well maintained.
  • The practice had infection control procedures which reflected published guidance.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available with the exception of a second oxygen cylinder as the practice provided conscious sedation.
  • The practice had systems to help them manage risk. Improvements could be made to the management of fire risks.
  • The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
  • The practice had staff recruitment procedures. Improvements could be made to the process for acquiring Disclosure and Barring Service (DBS) checks at the point of employment.
  • The practice could improve the process and procedures for the use of the cone beam computed tomography (CBCT) machine.
  • The clinical staff provided patients’ care and treatment in line with current guidelines.
  • Staff treated patients with dignity and respect.
  • The appointment system met patients’ needs.
  • The practice had effective leadership. Staff felt involved and supported and worked well as a team.
  • The practice asked patients for feedback about the services they provided.
  • The practice had an effective complaints procedure in place.

There were areas where the provider could make improvements and should:

  • Review availability of sufficient oxygen giving due regard to guidelines issued by the Standing Dental Advisory Committee: conscious sedation in the provision of dental care “Report of an expert group on sedation for dentistry” (Department of Health 2003).
  • Review the current fire risk assessment and implement the required actions including weekly fire alarm tests and bi-annual fire drills.
  • Review the protocols and procedures for use of the CBCT scanner / imaging equipment giving due regard to the HPA-CRCE-010 Guidance on the Safe Use of Dental Cone Beam CT (Computed Tomography) equipment in having quality assurance measures for the use of the Cone Beam Computed Tomography scanner (CBCT).
  • Review the practice's recruitment policy and procedures to ensure DBS checks are sought at the point of employment.
  • Review the process for documenting consent when using social media.