Updated 6 September 2019
We carried out this announced inspection on 30 July 2019 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
Darnall Dental Clinic is in Sheffield and provides mainly NHS and occasional private dental treatment to adults and children. The practice is an approved foundation dentist training practice. Foundation training practices have been approved by the dental deanery to provide training and support to newly qualified dentists.
There is level access for people who use wheelchairs and those with pushchairs. Free car parking spaces are available near the practice.
The dental team includes a principal dentist, six associate dentists, ten dental nurses, one dental hygiene therapist and a practice manager who is also a registered dental nurse. The practice has six treatment rooms. Extensive building work was ongoing to better utilise the existing building. This will provide two additional treatment rooms, a decontamination room and a staff area.
The practice is owned by a company and as a condition of registration must have a person registered with the Care Quality Commission 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 Darnall Dental Clinic is the principal dentist.
On the day of inspection, we collected five CQC comment cards filled in by patients. All comments received reflected positively on the service.
During the inspection we spoke with three dentists, three dental nurses 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 Friday 9am to 5:30pm.
Our key findings were:
- The practice appeared clean and well maintained. Measures were taken to ensure the building work did not impact on the cleanliness of the practice.
- The provider had infection control procedures which reflected published guidance.
- Improvement was required to bring Legionella management systems in line with the risk assessment.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- Improvements could be made to help the provider manage risk to patients and staff. For example, use of sharps items, control of substances hazardous to health and responding to patient safety alerts.
- The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The provider had thorough staff recruitment procedures.
- 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 provided preventive care and supporting patients to ensure better oral health.
- The appointment system took account of patients’ needs.
- The provider had effective leadership and culture of continuous improvement.
- Staff felt involved and supported and worked well 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 suitable information governance arrangements.
There were areas where the provider could make improvements. They should:
- Review the practice's Legionella risk assessment and implement any recommended actions, 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.
- Review the practice’s sharps procedures to ensure the practice is in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
- Review the practice’s arrangements for receiving and responding to patient safety alerts, recalls and rapid response reports issued by the Medicines and Healthcare products Regulatory Agency, the Central Alerting System and other relevant bodies, such as Public Health England.
- Review the practice's policy for the control of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure comprehensive risk assessments are undertaken.