Updated 23 April 2024
We carried out this unannounced focused inspection on 6 March 2024 under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions.
In response to information of concern received, we planned the inspection to check whether the 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 2 specialist dental advisers.
In response to the concerns raised we asked the following 2 questions:
- Is it safe?
- Is it well-led?
These questions form the framework for the areas we look at during the inspection.
Our findings were:
- Infection prevention and control procedures did not fully reflect published guidance.
- Systems to ensure the minimal standards of record keeping for general dentistry, sedation and dental implants were not effective.
- Systems were not in place to effectively monitor referrals to other dental or healthcare professionals.
- Systems and processes to deliver conscious sedation to patients following published guidance were not effective.
- Systems to ensure patients could be treated in an emergency were not effective.
- Systems to account for all dispensed medicines were not effective.
- Systems to help staff manage legionella, fire and clinical waste risk were not effective.
- Evidence was not available to demonstrate facilities and dental equipment were being appropriately serviced and maintained.
- Evidence of up-to-date staff training in respect to sedation, basic life support, immediate life support and paediatric immediate life support was not available.
- Improvement was needed to ensure effective leadership, oversight and management.
- Systems to ensure good governance in the longer term were not effective.
- Systems to support a culture of continuous improvement (audit) were not in place.
Background
Pitsmoor Dental Health Centre is in Sheffield and provides NHS and private dental care and treatment for adults and children.
There is step free access at the rear of the practice for people who use wheelchairs and those with pushchairs. Limited car parking spaces are available at the practice. A small car park is available near the practice. The practice has made reasonable adjustments to support patients with access requirements.
The dental team includes 3 dentists, 6 dental nurses, 1 dental hygienist, a practice manager and 3 receptionists. The practice has 4 treatment rooms.
During the inspection we spoke with 2 dentists, dental nurses, reception staff 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 to Thursday 9am – 5.30pm and Friday 9am – 2pm.
We identified regulations the provider is not complying with. They must:
- Ensure care and treatment is provided in a safe way to patients.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Full details of the regulations 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 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’.
- Take action to ensure the clinicians take into account the guidance provided by the College of General Dentistry and the Scottish Dental Clinical Effectiveness Programme when completing dental care records, including general dentistry, sedation and implants.
- 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.
- Implement processes and systems for seeking and learning from staff feedback with a view to monitoring and improving the quality of the service.