We carried out this announced inspection on 11 February 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 not 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 not providing well-led care in accordance with the relevant regulations.

Background

Chesterfield Road Dental Practice is in Sheffield and provides mainly NHS and some private treatment to adults and children.

There is portable ramp access for people who use wheelchairs and those with pushchairs at the rear of the practice. Road side car parking spaces, are available near the practice.

The dental team includes six dentists, nine dental nurses (three of whom are trainees and one is the reception manager), two dental hygienists and a dedicated receptionist. The team are supported by a practice manager. The practice has four treatment rooms and two instrument decontamination facilities.

The practice is owned by an individual 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 Chesterfield Road Dental Practice is the practice manager.

On the day of inspection, we collected 34 CQC comment cards filled in by patients.

During the inspection we spoke with three dentists, three dental nurses, one dental hygienist 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 Thursday 08:45 – 17:30

Friday 08:45 – 17:00

Our key findings were:

• The practice appeared clean and well maintained.
• Infection control procedures mostly reflected published guidance. Improvements could be made to bring processes fully in line with guidance.
• Systems to manage medicines and life-saving equipment could be improved.
• The practice had systems to help them manage risk to patients and staff, we identified that improvements could be made to the fire safety management systems, Legionella management and safer sharps management and injury protocols.
• The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The practice could not demonstrate that an electrical fixed wiring safety check had taken place since 2012.
• 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.
• The practice had a Closed-Circuit Television (CCTV) with voice recording system; its use and impact had not been assessed.
• Systems in place to monitor and track prescriptions and patient referrals were not consistent.
• Staff were providing preventive care and supporting patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• Leadership at the practice could be improved. Systems to monitor and embed staff training could be improved.
• 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.

We identified regulations the provider was 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 was not meeting are at the end of this report.