We carried out a comprehensive inspection of this practice on 23 June 2015. Breaches of legal requirements were found. After the inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to good governance.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Abbeydale Dental Care Centre-Sheffield on our website at www.cqc.org.uk.

Our findings were:

Are services well-led?

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

Background

Abbeydale Dental Care Centre provides dental services for NHS and private patients. The service is provided by the practice owner (principal dentist) and two associate dentists who are supported by three dental nurses (one of whom is a trainee) and two receptionists (one of whom is a trainee). The centre is located within a converted building which offers disabled access to the ground floor waiting area and one of the surgeries. The centre is located in a suburb of Sheffield and is close to local amenities and bus services. Opening hours are Monday to Friday 9am to 5pm.

The practice owner is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is run.

Our key findings were:

• The practice had started to audit dental care records and X-rays.
• The practice was now conducting monthly practice meetings.

We carried out an announced comprehensive inspection of Abbeydale Dental Care Centre on the 23 June 2015 to ask the practice the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

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

Are services effective?

We found that this practice was providing effective services 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 not providing well-led care in accordance with the relevant regulations.

Abbeydale Dental Care Centre provides dental services for NHS and private patients. The service is provided by the practice owner (principal dentist) and two associate dentists who are supported by three dental nurses (one of whom is a trainee) and two receptionists (one of whom is a trainee). The centre is located within a converted building which offers disabled access to the ground floor waiting area and one of the surgeries. The centre is located in a suburb of Sheffield and is close to local amenities and bus services. Opening hours are Monday to Friday 9am to 5pm.

The practice owner is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons 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 spoke with three patients who used the service and reviewed seven CQC comment cards that had been completed by patients prior to the inspection. The patients we spoke with were positive about the care and treatment they received at the practice. They told us they were involved in all aspects of their care and found the staff to be friendly and they were treated with dignity and respect.

Our key findings were:

• They had systems to assess and manage risks to patients, including infection prevention and control, health and safety, safeguarding, recruitment and the management of medical emergencies.
• The practice carried out oral health assessments and planned treatment in line with current best practice guidance, for example from the Faculty of General Dental Practice (FGDP).
• Staff received training appropriate to their roles.
• Information of care and treatment options and support was available to patients, for example information of the cost of treatment.
• Patients told us they were treated with kindness and respect by staff. Staff ensured there was sufficient time to explain fully the care and treatment they were providing in a way patients understood. Patients commented they felt involved in their treatment and that it was fully explained to them.
• Patients were able to make routine and emergency appointments when needed.
• The practice had a complaints system in place and there was an openness and transparency in how these were dealt with.
• Staff told us they felt well supported and comfortable to raise concerns or make suggestions.
• There was no audit system in place to monitor quality of services provided. There were also no regular staff meetings to discuss significant events, improvements or issues within the practice.

We identified regulations that were not being met and the provider must:

• Undertake regular audits, quality monitoring and risk assesments to ensure that services are providing quality care. You can see full details of the regulations not being met at the end of this report.
• Ensure that there are regular staff meetings to discuss any issues within the practice including significant events, complaints and discuss audit results. These meetings need to be documented. You can see full details of the regulations not being met at the end of this report.

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

• Ensure that all surgeries are well maintained and floors are adequately sealed to allow effective cleaning.
• Ensure extracted teeth containing amalgam are disposed of correctly.

Ensure there is a stock control system in place to ensure that out of date materials are disposed of.