Dearne Valley Dental Practice

We carried out this announced comprehensive inspection on 7 December 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.
• The practice had infection control procedures which reflected published guidance.
• Staff knew how to deal with medical emergencies. Improvements could be made to the monitoring protocol to ensure all medicines and equipment were available and in date.
• Improvements were needed to the systems used to help the provider manage risks to patients and staff. In particular relating to dental sharps, fire safety and Legionella.
• 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.
• 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.
• 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

Dearne Valley Dental Practice is part of TSJ Smile Limited, a dental group provider. The practice is in Goldthorpe in Rotherham and provides primarily NHS treatment for adults and children.

There is step free access, via the rear of the building, for people who use wheelchairs and those with pushchairs. The practice is located close to local transport routes and on-street car parking is available near the practice. The practice has made reasonable adjustments to support patients with access requirements.

The dental team includes 2 dentists, 2 dental nurses, 2 dental therapists, 1 practice manager and 1 receptionist. The practice has 3 treatment rooms.

During the inspection we spoke with 1 dentist, 1 dental nurse, the receptionist and the practice manager. The business and HR manager for the group was also at the inspection. We looked at practice policies, procedures and other records to assess how the service is managed.

The practice is open:

Monday, Tuesday and Wednesday from 9am to 6pm

Thursday from 9am to 5.30pm

Friday from 9am to 5pm

(The practice closes for lunch between 12.50pm and 1.50pm daily)

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 was not meeting are at the end of this report.

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

• Implement audits for prescribing of antibiotic medicines taking into account the guidance provided by the College of General Dentistry. In addition, the practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.