• Dentist
  • Dentist

Pitsmoor Dental Health Centre

139 Burngreave Road, Sheffield, South Yorkshire, S3 9DL (0114) 272 3076

Provided and run by:
Mr. Alan Moffatt

All Inspections

During an assessment under our new approach

We had undertaken a comprehensive inspection under our previous methodology of Pitsmoor Dental Health Centre on 6 March 2024 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We found the registered provider was not providing safe and well-led care and was in breach of regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We undertook a follow up on site focused assessment on 24 June 2024. This assessment was carried out to review the actions taken by the registered provider to improve the quality of care and to confirm that the practice was now meeting legal requirements. We found the practice had met regulations. The practice had systems to manage risks. Infection control procedures followed published guidance. Patients’ care and treatment was provided in line with current guidance. At the time of our assessment, we found that patients could access care, support and treatment when required. There was effective leadership and a culture of continuous improvement. Pitsmoor Dental Health Centre is in Sheffield and provides NHS and private dental care and treatment for adults and children. At the time of our assessment, the dental team included 2 dentists, 6 dental nurses, 1 dental hygienist, 1 practice manager and 3 receptionists. The practice had 4 treatment rooms. During the assessment we spoke with 1 dentist, 3 dental nurses, 1 receptionist and the practice manager. The practice is open: Monday to Thursday 9am – 5.30pm and Friday 9am – 2pm.

06/03/2024

During an inspection looking at part of the service

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.

13/03/2023

During an inspection looking at part of the service

We carried out this announced comprehensive inspection on 13 March 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, the following 5 questions were asked:

  • 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. Appropriate medicines and life-saving equipment were available.
  • The practice had recently introduced systems to manage risks for patients, staff, equipment, and the premises.
  • Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • The practice had staff recruitment procedures which mostly reflected current legislation. Protocols were introduced to obtain existing staff employment records.
  • 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.
  • There was effective leadership and a culture of continuous improvement. Systems to ensure good governance were ongoing.
  • Staff felt involved, supported, and worked as a team.
  • Systems were ongoing to embed new and existing processes after a period of staffing instability.
  • Systems were ongoing to ensure staff knew how to act on patient safety alerts and incident reporting.
  • 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

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. The practice has made reasonable adjustments to support patients with access requirements.

The dental team includes 2 dentists, 3 dental nurses, a dedicated decontamination dental nurse, a practice manager, and a receptionist. The practice has 4 treatment rooms.

During the inspection we spoke with 2 dentists, 3 dental nurses, the receptionist, 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.

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

  • Improve the practice's recruitment policy and procedures to ensure accurate, complete, and detailed records are maintained for all staff.
  • Improve the practice's processes for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken and the products are stored securely.
  • Implement practice protocols and procedures to ensure staff are up to date with their mandatory training and their continuing professional development.
  • Ensure an effective system is in place for receiving and responding to patient safety alerts and the recording, investigating, and reviewing incidents or significant events.

11 September 2013

During a routine inspection

Pitsmoor Dental Health Centre was located in two adjoining buildings. The centre occupied the whole of one building and the ground floor only of the adjoining building. Each building contained two surgeries and a patient's waiting area. Reception, a decontamination room and staff offices were located in the building which the centre occupied in full.

People's views and experiences were taken into account in the way the service was provided and delivered in relation to their care. Patients told us, 'I get given different alternatives and a written list of the different treatments with quotes' and 'They give all the information and then the choice is up to me'.

Care and treatment was planned and delivered in a way that ensured people's safety and welfare. People we spoke with told us, 'I wouldn't change anything', 'I think he [the dentist] is from heaven' and "It's an excellent service, unbelievable, totally first class',

Our observations and our review of records demonstrated that people received care and treatment in a clean environment with measures in place to minimise the risk of infection. One person said, 'They keep it minimal which I like, it's nice and open.'

The provider had a satisfactory recruitment and selection procedure in place to ensure that staff were appropriately employed.

We found that there were effective systems to regularly assess and monitor the quality of service that people received.