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Sussex Community NHS Foundation Trust Community Dental Services Evidence Appendix Brighton General Hospital
Elm Grove
Brighton
Tel: 01273696011
www.sussexcommunity.nhs.uk
Date of inspection visit:
11 to 12 September 2017
Date of publication:
xxxx> 2017
This evidence appendix provides the supporting evidence, which enabled us to come to our judgements of the quality of care offered by community dental services. It is based on a combination of information provided to us by the hospital, nationally available data, what we found when we inspected, information given to us from patients, the public and other organisations.
Community Dental Services
Good
Facts and data about this service
Sussex Community NHS Foundation Trust provides dentistry service from 10 locations across Sussex including six health centres and 4 hospitals. The service provides assessment and treatment for:
Patients with learning difficulties.
Patients with severe or complex medical problems.
Patients with mental health problems.
Patients with physical disability.
Older people with mobility restrictions or in residential care who require domiciliary care.
Adults with social/emotional/behavioural problems.
Adult phobic patients who wish to have treatment for their phobia.
The service also provides oral health promotion and education, restorative and orthodontic treatment.
The following services are provided:
Specialist dental care for patients who require services from dental staff with understanding and training in special needs who have difficulty in obtaining treatment from the General Dental Service.
Specialist services such as dental treatment under general anaesthesia (GA) or sedation, extractions under GA, domiciliary care and restorative treatment not readily available in the GDS.
GA is undertaken at Nuffield Hospital (Haywards Heath), St. Richard’s Hospital (Chichester) Brighton and Sussex University Hospital (Brighton)
Oral health promotion/education and training is provided in the community setting by a team of four staff visiting schools, rehabilitation and respite centres and voluntary groups in the community.
Information about the sites which offer community dental services at this trust is shown below:
Location site name Team/ward/satellite name
Central Clinic Emergency Dental Service - Worthing
Central Clinic Special Care Dentistry - Central Clinic
Chailey Heritage Clinical Services Special Care Dentistry - Chailey Heritage
Crawley Hospital Emergency Dental Service - Crawley
Crawley Hospital Special Care Dentistry - Crawley Hospital
Haywards Heath Health Centre Emergency Dental Service - Haywards Heath
Haywards Heath Health Centre Special Care Dentistry - Haywards Heath
Lancing Health Centre Special Care Dentistry - Lancing
Littlehampton Health Centre Special Care Dentistry - Littlehampton
Morley Street Clinic Oral Health Promotion
Morley Street Clinic Special Care Dentistry - Morley Street
Jubilee Dental Centre Emergency Dental Service - St Richards Hospital Chichester
Jubilee Dental Centre Special Care Dentistry - St
Richards Hospital,Chichester
Nuffield Hospital ( Haywards Heath), St Richard’s Hospital ( Chichester),
Brighton and Sussex University Hospital ( Brighton) Dental SCD Hospital GA sites
Haywards Heath Health Centre, Central Clinic, Jubilee Dental Centre and Morely Street Clinic
Dental SCD Domiciliary
the service safe?
Good
Mandatory training
Staff had access to and attended mandatory training appropriate for them to deliver safe care to
patients.
The trust had a mandatory training programme that included basic life support, information
governance, infection control, health and safety, fire safety, safeguarding children and adults,
mental capacity act, equality and diversity and manual handling.
Managers made sure they completed it. We saw data which indicated the service was exceeding
their targets consistently.
The trust set a target of between 85% and 90% for completion of mandatory training, and their overall training compliance was mostly met against this target.
A breakdown of compliance for mandatory training course between June 2016 and May 2017 for clinicians, nursing and admin staff in community dental services is shown below
Staff group Training module Trust Target
Required frequenc
y
# eligible staff this
year
# trained (YTD)
% trained (YTD)
Dentists Back Awareness 90% 2 Yearly 19 19 100%
Dentists Equality & Diversity
85% 3 Yearly 19 18 95%
Dentists Fire 90% Yearly 19 18 95%
Dentists Health & Safety 90% 3 Yearly 19 19 100%
Dentists Infection Control 90% Yearly 19 18 95%
Dentists Information Governance
90% Yearly 19 19 100%
Dentists Patient Handling 85% 2 Yearly 19 19 100%
Dentists Resus 85% Yearly 19 19 100%
Dentists Safeguarding Adults Basic
85% 3 Yearly 19
19 100%
Dentists Safeguarding Adults Level 3
85% 3 Yearly 19
0 N/A
Dentists Safeguarding Child Basic
90% 3 Yearly 19
19 100%
Dentists Safeguarding Child Level 3
85% Yearly 19
0 N/A
Nurses Back Awareness 90% 2 Yearly 23
Nurses Equality & Diversity
85% 3 Yearly 23
23 100%
Nurses Fire 90% Yearly 23 18 88%
Nurses Health & Safety 90% 3 Yearly 23 22 96%
Nurses Infection Control 90% Yearly 23
Nurses Information Governance
90% Yearly 23
22 96%
Nurses Patient Handling 85% 2 Yearly 23 23 100%
Nurses Resus 85% Yearly 23 23 100%
Nurses Safeguarding Adults Basic
85% 3 Yearly 23
23 100%
Nurses Safeguarding Adults Level 3
85% 3 Yearly 23
0 N/A
Nurses Safeguarding Child Basic
90% 3 Yearly 23
23 100%
Nurses Safeguarding Child Level 3
85% Yearly 23
0 N/A
Reception staff Back Awareness 90% 2 Yearly 8 7 88%
Reception staff Equality & Diversity
85% 3 Yearly 8
7 88%
Reception staff Fire 90% Yearly 8 6 75%
Reception staff Health & Safety 90% 3 Yearly 8 7 88%
Reception staff Infection Control 90% Yearly 8 6 75%
Reception staff Information Governance
90% Yearly 8
7 88%
Reception staff Patient Handling 85% 2 Yearly 8 0 N/A
Reception staff Resus 85% Yearly 8 0 N/A
Reception staff Safeguarding Adults Basic
85% 3 Yearly 8
7 88%
Reception staff Safeguarding Adults Level 3
85% 3 Yearly 8
0 N/A
Reception staff Safeguarding Child Basic
90% 3 Yearly 8
7 88%
Reception staff Safeguarding Child Level 3
85% Yearly 8
0 N/A
OHP Back Awareness 90% 2 Yearly 3 3 100%
OHP Equality & Diversity
85% 3 Yearly 3 3
100%
OHP Fire 90% Yearly 3 3 100%
OHP Health & Safety 90% 3 Yearly 3 3 100%
OHP Infection Control 90% Yearly 3 3 100%
OHP Information Governance
90% Yearly 3 3
100%
OHP Patient Handling 85% 2 Yearly 3 3 N/A
OHP Resus 85% Yearly 3 3 100%
OHP Safeguarding Adults Basic
85% 3 Yearly 3 3
100%
OHP Safeguarding Adults Level 3
85% 3 Yearly 3 3
N/A
OHP Safeguarding Child Basic
90% 3 Yearly 3 3
100%
OHP Safeguarding Child Level 3
85% Yearly 3 3
N/A
HQ staff Back Awareness 90% 2 Yearly 9 9 100%
HQ staff Equality & Diversity
85% 3 Yearly 9 9
100%
HQ staff Fire 90% Yearly 9 9 100%
HQ staff Health & Safety 90% 3 Yearly 9 9 100%
HQ staff Infection Control 90% Yearly 9 9 100%
HQ staff Information Governance
90% Yearly 9 9
100%
HQ staff Patient Handling 85% 2 Yearly 2 2 N/A
HQ staff Resus 85% Yearly 3 3 100%
HQ staff Safeguarding Adults Basic
85% 3 Yearly 9 9
100%
HQ staff Safeguarding Adults Level 3
85% 3 Yearly 9 9
N/A
HQ staff Safeguarding Child Basic
90% 3 Yearly 9 9
100%
HQ staff Safeguarding Child Level 3
85% Yearly 9 9
N/A
Source- Additional data request October 2017
At the time of our inspection the service had achieved higher than the 85 to 90% target for
completion of mandatory training in emergency life support, manual handling, fire safety, equality
and diversity, infection control, information governance and health and safety. Staff told us they
attended various training courses. The service supported staff in accessing mandatory training.
Safeguarding
We found Staff understood their safeguarding responsibilities and could describe the safeguarding policies and procedures. Staff had up to date safeguarding training at the appropriate level.
Special care dental services had seen 3165 patients aged 17 years or under between June 2016 and May 2017.
A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional.
No safeguarding information had been provided by the trust at core service level for community dental services.
At the time of our inspection staff told us three safeguarding referrals had been made to the appropriate authority between April and May 2017.
Arrangements were in place to safeguard adults and children from abuse that reflected relevant
legislation and local requirements.
Staff had regular training in safeguarding of vulnerable adults and child protection. Those
interviewed were able to provide definitions of different forms of abuse and understood the
safeguarding procedures, how to escalate concerns and relevant contact information.
Safeguarding training was mandatory for staff and trust data provided showed that 100% of staff
had completed level 2 safeguarding children and adults training. This was above the trust target of
90%. We saw records which showed staff were due to complete level 3 safeguarding children on
28 September 2017.
At the time of our inspection staff told us two safeguarding referrals had been made about the
service in the last 12 months. We saw records which showed that the incidents were investigated
and recorded appropriately.
The service had an effective process to identify children and vulnerable adults who did not attend
their dental appointments. Further follow up calls were made in addition to a ‘did not attend’ letter
returned to the referring dental practice.
Cleanliness, infection control and hygiene
Standards of cleanliness and hygiene were generally well maintained. Reliable systems were used to prevent and protect people from a healthcare associated infection.
The waiting room, surgeries and treatment areas all appeared to be clean and tidy and free from clutter. A dental nurse showed us how instruments were decontaminated. We observed an effective procedure was used to decontaminate instruments in line with published guidance issued by issued by the Department of Health, namely 'Health Technical Memorandum 01-05 -Decontamination in primary care dental practices (HTM 01-05). The service carried out infection control audits covering various aspects of infection control in dentistry. The audits showed the service achieved the essential quality requirements in infection control.
The service provided a risk assessment for Legionella, which had been carried out in the last 12 months and there was an action plan in place. This process ensured the risks of Legionella bacteria developing in water systems within the premises had been identified and preventive measures taken to minimise risk of patients and staff developing Legionnaires' disease. We saw records which showed water temperatures were being monitored. Hand washing facilities were available in each treatment room and included liquid soap and paper towels. All staff were observed to be arms bare below the elbows to enable good hand hygiene practices. Hand hygiene audits had been undertaken compliance was reported as 100%.
Personal protective equipment was available for staff (including gloves, masks or visors, safety glasses and aprons) and for patients (safety glasses and bibs). We observed these being used appropriately to aid effective infection control.
Two of the trusts sites namely Lancing Health Centre and Chailey Heritage Clinical Services did not have dedicated decontamination rooms. Instruments were cleaned and sterilised in the treatment room. Staff told us the decontamination of instruments did not take place when patients were present. We observed that at Lancing Health Centre there was not a systematic flow from dirty to clean in line with HTM 01-05. An area for improvement was identified as having a definitive action plan to show how these sites would move towards best practice and installing a dedicated decontamination room.
Environment and equipment
The design, maintenance and use of facilities and premises met patients’ needs. The maintenance and use of equipment kept people safe.
Waste was managed safely and clinical specimens were handled appropriately. This included the classification, segregation, storage, labelling, handling and, where appropriate, treatment and disposal of waste.
The dental equipment including all the dental chairs and lights were modern and appeared to be well-maintained. Annual servicing details for both the intra-oral and extra-oral x-ray machines were available and up-to-date. We saw that the service had a comprehensive maintenance schedule in place for their equipment. Electrical testing had been carried out and a label indicated when the next test was due.
There was a dedicated x-ray room containing an extra-oral machine.X-ray machines had clearly identified and appropriately sited isolation switches to switch the machine off in an emergency. Clear signage and safety warning lights were used in the x-ray room to warn people about potential radiation exposure.
The resuscitation equipment was secure and sealed and we found evidence that regular checks had been completed. An automated external defibrillator, portable suction machine, oxygen and associated breathing aids were available. Paediatric resuscitation equipment was also available in line with the Resuscitation UK and BNF guidelines.
Guidelines were available to inform staff how to respond in the event of a sharps or needle stick injury. This included the immediate first aid procedure and reporting of the incident. We saw that safety devices were used to enable the safer disposal of sharps and this complied with the Safe Sharps Act 2013. Sharps bins were used safely. They were correctly stored, assembled, labelled and not overly full and were disposed of by the recommended use by date, all in accordance with the European Union directive for the safe use of sharps.
We found there were suitable arrangements were used to ensure the safety of the radiography equipment and we saw local rules relating to each x-ray machines were displayed in accordance with guidance. X-ray audits were carried out annually to ensure films were of a satisfactory quality. An audit was completed for X-rays taken between April 2015 to April 2016 and showed more than 70% of all x-rays were graded as a one, which denotes the highest quality, and less than 10% were graded in the lowest category. This falls within national guidance. Dentists recorded the reasons for taking x-rays in the patient’s clinical notes. All images were checked for quality assurance and fully reported on.
Assessing and responding to patient risk
We saw risk assessments, screening tools and record charts were used to minimize risk to
patients. Effective policies and procedures were in place to manage a patient in an emergency.
Comprehensive Medical History Questionnaires (MHQs) were completed by/for each patient, at
their first appointment and updated at subsequent visits. The MHQ included information about the
patient’s medical history and medication.
Full examinations were carried out on each patient at each check-up including soft tissue
examination, periodontal examination, occlusion (bite) and diet.
At the time of our inspection we found the dental waiting list had 397 patients waiting for treatment,
including domiciliary care, and there was oversight of the risks associated with this. There was an
effective system to ensure that patients on the waiting lists were reviewed and dental managers
were fully aware of their waiting times and numbers of patients waiting to be seen. Referrals were
assessed against the established access/exclusion criteria and either accepted by the service or
not.
Where relevant, preventative dental information was given in order to improve the outcome for the
patient. This included dietary advice and general dental hygiene procedures such as brushing
techniques or recommended tooth care products. The patient dental care record was updated with
the proposed treatment after discussing options with the patient. A treatment plan was then given
to each patient and or carer and this included any cost involved.
Dental general anaesthesia (GA) was delivered following the World Health Organisation surgical
safety checklist and five steps to safer surgery to prevent incidents, such as a never event from
occurring. Patients received an assessment at a separate appointment before GA and a
comprehensive treatment plan was then formulated. A further pre-operative assessment
appointment was carried out by the day surgery unit nurse prior to the GA appointment. Staff
ensured patients and carers received appropriate post-operative instructions following dental
surgery under GA. This minimised the risk of the patient suffering from post-operative
complications such as post extraction haemorrhage and infections.
We saw evidence which showed -conscious sedation such as inhalation sedation (IS) and
intravenous sedation (IV) were delivered according to the standards set out by Intercollegiate
Royal Colleges Guidelines for Conscious Sedation, 2015.
Potential risks were taken into account when planning services, for example seasonal fluctuations
in demand, the impact of adverse weather, or disruption to staffing.
Staff checked the emergency equipment each day. The results of these checks were logged and initialled by the person completing them. We saw examples of these logs for both current and past months. All staff had completed training in basic life support and medical emergencies.
Biohazard (body fluid) spillage and mercury spillage kits were available if needed. Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER) were in place. This is a reporting mechanism published by the Department of Health, September 2012 with regard to radiation exposures much greater than intended and diagnostic reference levels. There had been no IRMER reports submitted in the last 12 months for the community dental service.
Staffing
The service had enough staff with the right qualifications, skills, training and experience to keep
people safe from avoidable harm and abuse and to provide the right care and treatment. Staffing
levels were adequate to meet patient need at the time of our inspection.
Staff fill rates compare the proportion of planned hours worked by staff (Nursing, Midwifery and
Care Staff) to actual hours worked by staff (day and night). Mental health trusts are required to
submit a monthly safer staffing report and undertake a six-monthly safe staffing review by the
director of nursing. This is to monitor and in turn ensure staffing levels for patient safety.
The below table covers staff fill rates for registered nurses and care staff during December,
January, March and April. Across Public Health and Community Health Services.
Month CQC core
service Staffing groups
Planned
staff – WTE
Actual
staff –
WTE in
month
Actual staff
– whole
number /
headcount
31/12/2016 All Core
Services
Public Health and
Community Health
Services
4530.57 3796.14 4869.00
31/01/2017 All Core
Services
Public Health and
Community Health
Services
4532.26 3811.99 4885.00
28/02/2017 All Core
Services
Public Health and
Community Health
Services
4531.27 3823.83 4899.00
31/03/2017 All Core
Services
Public Health and
Community Health
Services
4531.27 3828.91 4903.00
30/04/2017 All Core
Services
Public Health and
Community Health
Services
4585.16 3830.66 4904.00
31/05/2017 All Core
Services
Public Health and
Community Health
Services
4573.45 3860.21 4930.00
At the time of our inspection staffing levels, skill mix and caseloads were planned and reviewed so
that patients received safe care and treatment at all times, in line with relevant tools and guidance.
Staff told us there were always enough staff to maintain the smooth running of the service and
there were always enough staff on duty to keep patients safe.
Arrangements for using bank, agency and locum staff were designed to keep people safe and
included an appropriate induction process. However, from September 2016 to September 2017,
we were told the service did not regularly use temporary bank and agency workers.
Staff roles and responsibilities were clearly defined. There were dedicated staff who provided
regular domiciliary care. The service employed oral health educators and dental therapist as well
as dentists and dental nursing staff. Dentists and dental nurses provided cover to other clinics
during annual leave and sickness.
During month 12, the trust reported an average vacancy rate for all community dental staff of
2.2%.
The table below shows the community dental staff vacancies as of March 2017.
Staff group Total number of
substantive staff
Total number of vacancies
(excluding seconded staff)
(establishement)
Dental Assoc Specialist 2.15 0.15
Dental Consultant 1.65 0
Dental Nurse 27.22 -0.18*
Dental Officer 3.39 0
Nurse 1 0
Senior Dental Officer 6.14 0.55
* Indicates over-establishment.
Between June 2016 and May 2017, the trust reported an overall turnover rate of 7.2% in
community dental services.
Between June 2016 and May 2017, the trust reported an overall sickness rate of 3.0% in community dental services.
During the reporting period, this core service reported that there were no cases where staff have
been either suspended or placed under supervision. No staff have been suspended and none
were placed under restricted practice.
Quality of records
Patients’ individual care records were written and managed in a way that kept people safe.
There was a mix of computerised and paper records. Records seen were accurate, complete, legible, and up to date. The computers were password protected and paper records were stored securely in locked cabinets. We looked at ten patient treatment records. Staff showed us a capacity assessment for a patient who lacked the capacity to make a treatment decision and who was treated in their best interest. Staff explained the procedure that was followed in the best interest meeting. We saw meetings had been held with other relevant healthcare professionals to discuss the treatment options.
Electronically stored records were password protected and only accessible to staff who had an appropriate security password. We spoke with community dental services staff about the electronic patient records system, which was used by staff across all of the trust’s community dental clinics. Staff told us their biggest concern was that the electronic patient record system had not always provided a consistent, reliable and effective system for the recording and retention of patient information.
Staff told us the software required updating and difficulties encountered included the computers freezing and staff were not able to access records during these incidents.
The clinical lead confirmed that the issues with the software had been identified as a risk at both directorate and divisional levels and had been monitored via the relevant risk register. An area for improvement had been identified as there was no action plan in place with a definitive date to address the issues with the software.
Staff were able to access patient information such as diagnostic imaging records and reports, medical records and referral letters appropriately through electronic records and some paper records. Access to electronic records was password protected. Records were updated by dentists and dental nurses directly after each consultation.
Medicines
There were effective systems to ensure the safe use of medicines. This included safe systems for medication storage, stock control, prescribing, administration and disposal.
Emergency drugs were kept in a sealed bag and stored which enabled rapid staff access. Medicines management for medical emergencies in primary dental care was in line with the guidance set out in the British National Formulary (BNF).
Patient records included allergies and reactions to medication, such as antibiotics. Prescriptions numbers and batch numbers of medication used were recorded in patient’s records. This was in line with NHS Protect, security of prescription forms, 2015.
Local anaesthetics, antibiotics and high concentration fluoride toothpastes were prescribed according to current clinical guidelines.
The records we viewed were complete, and provided an account of medicines used and prescribed which demonstrated patients were given medicines only when necessary.
The dental service had completed an audit of prescribing antimicrobials in April 2017. This was in line with the trust policy of prescribing antimicrobials where there was a clear clinical need. None of the locations we visited during inspection stored or provided general anaesthetic.
Safety performance
The service demonstrated good safety performance with no serious incidents, never events or
near misses. The quality of the care delivered was monitored continuously through various
performance tools, and taken account of at a local and trust level. This was evidenced in the
meeting minutes we viewed as well as the conversations we had with staff.
Incident reporting, learning and improvement
Trusts are required to report serious incidents to Strategic Executive Information System (STEIS).
These include ‘never events’ . Never events are serious incidents that are entirely preventable as
guidance, or safety recommendations providing strong systemic protective barriers, are available
at a national level, and should have been implemented by all healthcare providers. Each never
event type has the potential to cause serious patient harm or death. However, serious harm or
death is not required to have happened as a result of a specific incident occurrence for that
incident to be categorised as a never event.
In accordance with the Serious Incident Framework 2015, the trust reported no serious incidents
(SIs) in community dental services, which met the reporting criteria, set by NHS England between,
June 2016 and May 2017.
Between June 2016 and May 2017, trust staff in this core service reported no serious incidents.
The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which
all contain a summary of Schedule 5 recommendations, which had been made, by the local
coroners with the intention of learning lessons from the cause of death and preventing deaths.
In the last year, there have been no prevention of future death reports sent to the trust regarding
this core service. 1
When things went wrong, the service reviewed what had happened and understood the need to
learn from the incident to make sure the safety of the service was improved. The clinical director
and the senior management team were responsible for investigating. Staff told us that incidents
with low harm or no harm were reported and investigated.
Managers shared incidents and learning with staff through regular staff meetings and staff told us
about changes made as a result. We saw evidence in staff meeting minutes which showed the
learning from incidents was discussed.
Staff understood their responsibilities to raise concerns, and record and report safety incidents and
near misses. The service had an electronic incident reporting system - and standard reporting
forms for staff to complete. Staff recorded incidents that occurred in patients’ homes using this
system.
Staff understood the process for accident and incident reporting under the Reporting of Injuries,
Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR). There had been no
accidents or incidents which had required notification under the RIDDOR guidance in the last 12
months.
The clinical director demonstrated an understanding of their duty of candour. Duty of Candour is a legislative requirement for providers of health and social care services to set out some specific requirements that must be followed when things go wrong with care and treatment.
There had been three incidents requiring Duty of Candour reported in the year to September 2017. We saw records which showed that staff informed patients about the incidents, providing truthful information and an apology when things went wrong.
Is the service effective?
Good
Evidence-based care and treatment
The service provided care and treatment based on national guidance and evidence of its
effectiveness. Managers checked to make sure staff followed guidance.
Special care dentistry services had completed the following audits from June 2016 to May 2017.
A re-audit to examine consent taking for Adult IV patient’s treated by Special Care Dentistry
Levels of anxiety in patients referred as new patients to Sussex Community Trust Special Care
Dental service
Basic Periodontal Examination in under 18s audit and re-audit CSD025
A Service Evaluation of a new tooth brushing programme including non-foaming toothpaste at
Chailey Heritage for people with cerebral palsy unable to eat and drink safely (Eating and Drinking
Ability Classification System Levels V).
Audit of Radiograph quality at Special Care Dental Services – 2017
1 Routine Provider In formation Request
An audit to Investigate Compliance with NICE Dental Recall Guidelines in the Special Care
Dentistry Service SCFT – 2nd
Cycle
An audit of antibiotic prescription use within the special care dental services, in accordance with NICE guidelines for the treatment of a dental abscess July 2015.
Paediatric GA at Jubilee Dental Centre (St Richards Hospital) Consent Audit
The service followed national and local guidance including guidance published by the Royal
Colleges, British Dental Association and National Institute for Health and Care Excellence (NICE).
Dentists, dental therapists and dental nurses working in the service used national guidelines to
ensure patients received the most appropriate care. This included guidance produced by the
British Society for Disability and Oral Health (BSDH) and the Faculty of General Dental Practice.
Dentists and dental nurses we spoke with understood these guidelines and the standards that
underpinned them.
NICE guidelines and guidance from the Faculty of General Dental Practice on antibiotic
prescribing and the taking of radiographs was also being used.
Consultations, assessments and care planning and treatment were carried out in line with
recognised general professional guidelines.
The service received national patient safety alerts such as those issued by the Medicines and
Healthcare products Regulatory Agency. Where relevant, these alerts were shared with all
members of staff by the dental nurse manager at staff or clinic meetings and by email.
Special Care Dentistry for patients with complex medical, mental health and social impairments
was delivered according to best practice as set out by the BSDH including domiciliary care.
Policies were used to ensure patients were not discriminated against. Staff were understood these
policies and gave us examples of how they followed this guidance when delivering care and
treatment for patients.
Policies we reviewed reflected national guidance with appropriate evidence and references. Staff
we spoke with could direct us to these policies. All policies and procedures were available and
accessed through the trust’s intranet.
The dental records of consultations observed during the inspection, included clear plans of care,
which reflected best practice, including the record of discussions with patients and carers about
planned treatments and oral health.
Nutrition and hydration
We saw that the service had taken steps to promote nutrition and hydration advice to patients. The service’s oral health promotion team actively promoted oral health in the community. This included programmes in the child health clinics on a healthy diet and tooth brushing. Patient advice and information leaflets were available which provided nutrition and hydration advice for patients. These included written and pictorial representations, which were appealing to adults and children. The service displayed posters and leaflets about healthy eating, where available. The trust website had health promotion videos on tooth brushing and visiting the dentist. Children and adults having procedures under general anaesthetic were appropriately advised by dentists about the need to fast before their procedure. Staff were able to describe the fasting advice they gave to patients who were undergoing a general anaesthetic. When we spoke to the
relative of a patient who had received a general anaesthetic, they confirmed that they had received advice about fasting.
Pain relief
Dentists assessed patients appropriately for pain and other urgent symptoms. For example, in
cases of very young children where local anaesthesia was not appropriate for tooth extraction,
general anaesthesia under the care of a hospital anaesthetist was used as an alternative.
Dentists prescribed and administered local anaesthesia for patients for the relief of pain during
dental procedures, such as dental fillings and extractions.
A patient having treatment during our visit told us it was pain free.
Patient outcomes
The service participated in some local assessments to monitor the quality of service patients
received. Clinical audits demonstrated the implementation of national guidance including NICE
guidelines for recall intervals, consent for adult patients undergoing intravenous (IV) sedation,
levels of anxiety for new patients, tooth brushing for patients with cerebral palsy and access to
dental care for patients with early stage dementia. At the time of our inspection the service was
undertaking a record keeping audit.
Preventive care across the service was delivered using the Department of Health’s ‘Delivering
Better Oral Health Toolkit 2013’. Adults and their carers attending services were advised during
their consultation of steps to take to maintain healthy teeth. Tooth brushing techniques were
explained to them in a way they understood. Across the sample of dental care records reviewed,
we observed all demonstrated the dentist had given oral health advice to patients.
Oral health was promoted in the community by a dedicated team of oral health educators. Staff
told us there was multidisciplinary working with the health visitors and nurses at the care homes
Oral health promotion was provided in a wide range of locations including older people day
centres, rehabilitation centres, hostels, child health clinics and early year’s centres.
The service had carried out a survey, commissioned by Public Health England, on the condition of
teeth among all five year old children. At the time of our inspection the results of the survey had
not been analysed.
Competent staff
At the time of our inspection staff told us the trust had a clinical supervision policy. The trust
required two clinical supervision meetings in a year for all staff. We saw records which showed
that all staff had clinical supervision meetings which exceeded the minimum stated in the trust
policy. Clinical supervision was recorded in staff files.
At the time of our inspection we observed regular annual appraisals had been undertaken. From
September 2016 to September 2017, 100% of dental staff had received their annual appraisal.
New staff underwent an induction process. Staff received assistance to support new staff during
induction.
Multidiciplinary working and coordinated care pathways
There were suitable arrangements for working with other health professionals to ensure quality of
care for their patients. There was effective collaboration and communication amongst all members
of the multidisciplinary team to support the planning and delivery of patient centred care.
The service maintained close working relationships with children’s centres, the school nursing
service, health visiting teams, learning disability teams and drug and alcohol support to ensure
that vulnerable groups requiring dental care received treatment in a timely manner. Staff worked
together to assess and plan ongoing care and treatment in a timely way when people were due to
move between teams or services, including referral, and discharge.
Clinic information was shared with the patients’ general dental practitioner or other health
professional in letter format. The service produced these letters following the appointment and
sent copies to their general dental practitioner or other health professional. Copies were provided
for patients.
Health promotion
The oral health promotion team worked closely with health visitors and school teachers as part of
a multidisciplinary team to promote good oral healthcare. For instance, the team ran the ‘Early
Parenting Assessment’ initiative along with health visitors at the child health clinic. This
encouraged parents to become involved in decisions about their child’s dental health.
The health promotion team worked closely with NHS England on the ‘Mouth Care Matters’
initiative. The aim of the initiative was to improve oral health and healthcare principally for those
in bedded units in acute hospitals. They have also been involved in Improving Oral Health of
the Older Persons Initiative (IOHOPI). The aim of the initiative was to improve oral health and
healthcare principally for those residents in care homes. The health promotion team had worked
staff in care homes to develop care plans for residents. Staff also received health promotion
advice on tooth decay, gum disease, how to assess tooth brushing and caring for dentures.
The service had a healthy eating initiative for the homeless. The project was delivered in a hostel
and focussed on reducing sugar intake. The health promotion team was able to educate the
homeless as well as the nursing staff.
Staff told us that they liaised regularly with GP’s, carers, welfare agencies, safeguarding boards,
mental health advocates, and nursing homes in order to ensure that patients received the care
they needed. We saw evidence in records of patients that we reviewed of liaison between the
dental officer and the learning disability team, the independent mental health advocate, and taking
part in best interest meetings.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards
The trust did not provided us with Deprivation of Liberty Safeguard (DoLS) applications that were
made to the Staff understood the legal requirements of the Mental Capacity Act 2005 (MCA) and
applied these requirements when delivering care. Staff had access to social workers and staff
trained in working with vulnerable patients, such as their safeguarding lead.
Staff we spoke with understood Gillick competence. The Gillick competence is a term used to
decide whether a young person is able to consent to their own medical treatment, without the need
for parental permission or knowledge. The dentists and dental nurses understood the need to
consider this when treating young people under 16.
All staff received mandatory training in consent, safeguarding vulnerable adults and the Mental
Capacity Act 2005, and understood the relevant consent and decision making requirements of
legislation and guidance. Staff had completed MCA training and the dentist had also completed
Deprivation of Liberty Safeguards (DoLS) training.
Staff we spoke with demonstrated an understanding of the principles of the MCA and how this
applied in considering whether or not patients had the capacity to consent to dental treatment. We
were shown the dedicated forms used to gain consent from patients who did not have the capacity
to make their own treatment decisions. These forms were comprehensive and appropriate for their
use including a flow chart and space for a second opinion dentist to sign. We saw two examples of
these completed consent and best interest forum forms.
There was a system for obtaining consent for patients undergoing general anaesthesia, inhalation
sedation and other operative dental treatment. Staff discussed treatment options, including risks
and benefits, with each patient their parents, guardians or carers. Responsible adults were asked
to read and sign these before starting a course of treatment.
Is the service caring?
Good
Compassionate care
Staff were observed being kind, compassionate and caring while interacting and treating patients.
We observed staff treating patients with dignity and respect. We heard and observed staff using language that was appropriate to patients’ age or level of understanding. They used previous attendance notes and patient knowledge to communicate in a manner which met the individual’s needs. Personal dignity was maintained at all times, ensuring doors were closed to prevent others entering. Staff told us they ensured longer appointment slots were available for very anxious or nervous patients. Dentists and dental nurses spent extra time preparing in advance for patients with special needs. This included ensuring all staff involved in the patient’s care and treatments understood the specific individual needs of the patient.
Emotional support
Staff were clear on the importance of emotional support needed when delivering care and fully understood the emotional impact dental treatment could have on a patients’ well-being. They understood the individual needs of each patient and had a breadth of experience in ensuring the emotional impact was minimised. We saw notes where the dental team had liaised with the patient’s psychological support team to ensure appropriate care was provided at all times. All staff showed patience and understanding when interacting and treating patients. We saw and were told they provided timely support and information to patients to cope emotionally with their care and treatment.
Staff had a good awareness of patients with complex needs and those patients who may require additional support who displayed anxious or challenging behaviour during their visit to the service.
Understanding and involvement of patients and those close to them
Patients we spoke with felt well informed about their care and treatment and said they felt appropriately involved in the planning of treatment.
New patients and/or their carers were asked to complete a comprehensive medical history and a dental questionnaire. Staff were available to help with the form if required. This questionnaire enabled the clinicians to gather important information about their previous dental, medical and relevant social history. They also aimed to capture details of the patient’s expectations in relation to their needs and concerns. The information informed treatment options and ensured records were comprehensive and always available to protect the safety and well-being of patients.
Young children and people with a learning disability were given time and support to understand what was involved in their treatment. Dentists and dental nurses spoke directly to the patient but also included their carer in explanations and discussions.
Is the service responsive?
Good
Planning and delivering services which meet people’s needs
Dental managers worked with other health and social care providers and commissioners to plan to
meet the needs of people in the area, particularly those with complex needs, long-term conditions,
or life-limiting conditions.
Facilities and premises were appropriate for the services that were planned and delivered.
The service provided oral health care and dental treatment for children and adults that have
impairment, disability and/or a complex medical condition and those who are nervous or dental
phobic. Domiciliary dental services were provided where dental staff visited patients in their own
home or a nursing and residential environment. Domiciliary dental checks were carried out if it was
not possible for a patient to attend a clinic. Domiciliary treatment included dental assessment and
emergency care.
There was an efficient appointment system - to respond to patients’ needs. There were vacant
appointment slots for the dentist to accommodate urgent or emergency appointments.
Dentists had clinical freedom to adjust time slots to consider the complexities of the patient’s
medical, physical, psychological and social needs.
Sufficient staff were available to give extra time to patients with more complex needs, for example
patients who were needle phobic were given extra time for procedures and distraction techniques
were used where possible.
In line with national guidance, dental treatment for patients requiring a general anaesthetic was
carried out in a local hospital with critical care facilities.
Domiciliary visits were provided for older people living in residential care or their own homes.
There was adequate seating in the reception and waiting area. The treatment rooms had extra
chairs for carers to sit during treatment.
Parking was available for patients at the locaions we visited.
Patients had access to a variety of information about their dental treatment in leaflet form. This
information included pre and post-operative instructions and advice to help them manage their
dental care effectively before, during and after any treatment received.
Meeting the needs of people in vulnerable circumstances
The service planned to take account of the needs of different people, for example on the grounds
of age, disability, gender, gender reassignment, pregnancy and maternity status, race, religion or
belief and sexual orientation.
The service had recognised the needs of different groups in the planning of its service. Staff told
us they treated everybody equally and welcomed patients from a range of different backgrounds,
cultures and religions. Reception staff told us they had access to a translation service should it be
required.
Reasonable adjustments were made so that disabled people could access and use the service on
an equal basis to others.
The service was commissioned to specifically provide access to dental services for vulnerable
adults and children. The service had also considered the needs of patients with mobility issues.
The premises had appropriate wheelchair access for patients with limited mobility and had
disabled toilet facilities.
The training records indicated that all staff received regular update training in equality, diversity
and human rights.
The largest ethnic minority group within the trust catchment area is ‘other white’ with 5.24% of the
population.
Please note that the trust have not provided us with core service specific data – this data is
trustwide.
Ethnic minority group
Percentage of catchment
population (if known)
First largest White Other 5.24
Second largest Asian/Asian British: Indian 1.21
Third largest Asian/Asian British: Other Asian 1.12
Fourth largest White: Irish 1.0
The service was primarily a referral based specialised service providing continuing care to a targeted group of patients with additional needs due to physical, mental, social and medical impairment.
Staff described to us how they had supported patients with additional needs such as a learning disability. They ensured that patients were supported by their carer or a relative and that there was sufficient time to explain fully the care and treatment they were providing in a way that patients understood.
Staff explained how they helped to support people living with dementia and some staff had accessed additional training in dementia care in order to understand the condition and how to help patients more effectively.
An oral health education team was available to support the dentistry service. This enabled treatment to be backed up by preventative education from the oral health educators in the patient’s own homes and schools with their parents or carers. The oral health education team reached out to vulnerable groups including the homeless and those with drug and alcohol dependence.
The service was able to accommodate patients in wheelchairs or who needed specialist equipment. There was sufficient space to manoeuvre and position a person using a wheelchair in a safe and sociable manner.
Preventative dental information was given during consultations in order to improve the outcomes for patients. This included dietary advice and general dental hygiene procedures such as brushing techniques or recommended tooth care products.
Access to the right care at the right time
The total number of referrals to the dental service had increased since the previous year. At the
time of out inspection the service received a cumulative 1, 723 referrals for special care dentistry
and 313 for domiciliary care.
Waiting lists for the service varied between four to seventeen weeks.Initiatives taken to reduce the
waiting list included calling patients to fill short notice cancellation slots and staff working additional
sessions on the rota.
Staff reported low cancellation rates and ‘did not attend’ (DNA) rates overall. At the time of our
inspection we noted that the Morley Street Dental Clinic accounted for 47% of all DNA and
cancelled appointments from April 2017. The service was in the process of pilotting a weekly drop
in service to reduce the number of DNA and cancelled appointments. The service monitored these
rates on a monthly basis.
All referrals and discharges were dealt with in a timely manner. New referrals were screened to
ensure they met the referral criteria and were fully completed. There were clear referral systems
and processes to refer patients into the service, which ensured the efficient use of NHS
resources. Referrals were made by general dental and medical practitioners and other health care
professionals and residential care homes. We saw an effective system was used to ensure that
referrals were managed without any undue delay to patients.
Information regarding the opening hours was available on site. There was an answer phone
message which provided information about opening hours as well as how to access out of hours
treatment from other providers. Some emergency appointments were kept free each day so the
service could respond to patients in pain. Patients unable to access the services were visited in
their own homes, care homes or nursing homes.
During our inspection, appointments were running to time and patients waiting told us that they
had not experienced any delays previously. Staff told us if delays became apparent, they would
explain this to the patients waiting and if necessary offer to rebook appointments if clinics overran.
Learning from complaints and concerns
Community dental services received seven complaints between June 2016 and May 2017. The
main complaints themes were those of appointment delays or cancellation (outpatients).
Total
Complaints Fully upheld
Partially
upheld Not upheld
Referred to
Ombudsman
Upheld by
Ombudsman
7 2 4 1 0 0
The trust received 135 compliments related to community dental services during the last 12
months from June 2016. These accounted for 7.16% of all compliments received by the trust as a
whole.
At the time of our inspection the service had reported a further two complaints between June and
September 2017. Informal complaints were handled by staff at the time where possible or directed
to the Patient Advisory Liaison Service (PALS) and to the Friends and Family information leaflets.
The clinical director logged and managed all complaints. Each one, both formal and informal, were
discussed at staff meetings to allow learning and reflection to take place. We saw meeting
minutes, which confirmed this had taken place.
Information on how to complain was accessible on the trust website, information leaflet and also
throughout the service. Details were provided telling patients how to raise a complaint about the
care they had received.
At the time of our inspection the service collected and analysed the results of the NHS Friends and
Family test. The results showed that 97 – 100% of patients would be extremely likely or likely to
recommend the service.
Is the service well led?
Good .
Leadership
The service was led by a clinical director. The clinical director maintained overall responsibility
and accountability for the running of the service. The clinical director fostered a culture of
accountability by devolving responsibility to other appropriate individuals within the service.
The senior management team were responsible for the day to day running of the service and
provided support for the clinical director. The dental nurse manager was a strong and visible
leader. The senior management team ensured the dental service ran effectively.
The dental management team were responsible for passing information upwards to the trust
managers and downwards to the clinicians, dental nurses and reception team on the front line.
The structure appeared to be effective and was confirmed when we spoke to various members of
staff and reviewed staff meeting minutes.
Staff confirmed that they felt valued in their roles within the service and the local management
team were approachable, supportive and visible at all times.
We found the relationship between the staff and the local management team was strong, and staff
members at all levels reported there was an open door policy. Staff told us if they had concerns
regarding the service they would feel comfortable speaking directly to their line manager.
The culture of the service was one of continuous learning and there was a drive to improve
services.
Vision and Strategy
The vision of the service was to improve the oral health of all patients accessing their services and
to promote good dental hygiene to the population of Sussex. The strategy was documented as: To
Provide high quality patient-centred care; Encourage and act upon patient feedback and to
continually improve patients’ experience; Actively support and encourage personal and
professional development to ensure the highest standards are maintained and developed; Improve
working conditions at clinics to ensure high standards and staff & patient safety; Ensure the
service is accessible and flexible to meet the special needs of patients; Improve the productivity
and efficiency of the service through the efficient use of resources and to be pro-active in time
management to meet contractual requirements.
The service had an evolving strategy which staff knew about and said they had been involved in
developing. We saw that a plan had been developed in order to fully implement the service
strategy.
Dental staff we spoke with said the service had a forward thinking and proactive clinical lead that
was well supported by senior managers within the trust.
Culture
We were told staff were open to ideas, willing to change and were able to question practice within
their teams and suggest new approaches.
We observed that staff were very passionate about working within the service and proud to be
providing good quality care for their patients. Staff spoke about their work and conveyed their
dedication to what they did.
The culture of the service included continuous learning and developing both for individual staff and
for the service as a whole. Staff worked well together as a team and respected each member’s
individual contribution.
Staff had a ‘can do’ philosophy about their practice and the challenges they faced. There was a
happy and calm working environment which was positive for patient care.
Staff understood the whistleblowing policy on raising concerns about the service, including the
performance of other staff, and said they would feel confident in accessing the process if
necessary.
We were satisfied, having spoken to a range of staff, that the service understood and applied the duty of candour. The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable’ safety incidents’ and provide reasonable support to that person. The clinical director told us there had been three duty of candour incidents in the last 12 months. Two of these incidents related to correspondence being given to incorrect patients. The third incident related to care provided during root canal treatment. We saw records which showed a full explanation was given to patients promptly. The service investigated the incidents and put mechanisms in place to prevent recurrence.
Governance, risk management and quality measurement
There was a governance framework, which included regular meetings attended by staff of all
grades and professions. We saw minutes of these meetings which were well attended and where
risk and quality assurance was discussed.
The governance systems and risk management structures ensured action plans had been
developed for most of the identified risks.
Feedback from people who use services was regularly discussed along with updates on actions
from the risk register. There were monthly staff meetings at departmental level where concerns
and service delivery issues were discussed. All staff attended these meetings regularly which
helped to ensure they were fully involved with improving the service.
The service maintained a risk register. This register contained necessary information to identify, track and learn from resolution of risks. It listed the risk owner for each risk identified. Staff we spoke with knew the issues on the risk register. As at September 2017 the risk register had five risks on it, of which one had a current rating of ‘minor’ and four of moderate. Two moderate risks concerned the lack of appropriate decontamination facilities at Lancing Health Centre and Chailey Dental clinic. The risks had been identified in July and September 2016. The risk register stated the risk would continue to be reviewed monthly and quarterly at meetings. On inspection we found there was no definitive action plan to mitigate the risk. Another moderate risk was related to the IT service. The software could not be updated if the server was not updated from the 2013 version. There were functionality problems with the system which ran slowly affecting its efficiency. At inspection there was no timeframe for and schedule to update the IT system to a new platform.
A programme of audits assured quality. We reviewed the audits and action plans for recall
intervals, consent for adult patients undergoing IV sedation, levels of anxiety for new patients,
tooth brushing for patients with cerebral palsy and access to dental care for patients with early
stage dementia. At the time of our inspection the service was undertaking a record keeping audit.
Engagement
Friends and Family Test feedback forms were available for patients in the waiting area and
feedback was used to help inform service plans and improvements. Feedback was generally very
positive.
The service had a values based appraisal process which included a mandatory section on staff
wellbeing, which encouraged discussion and an opportunity to identify further support.
Staff told us of the various ways the trust engaged with them including team brief and via all staff
user emails. Staff told us they regularly reviewed the team briefings and found them useful.
The service gathered feedback from staff through staff meetings and discussions. Staff told us
they would not hesitate to give feedback and discuss any concerns or issues with colleagues and
management.
NHS England commissioned the service and so the vision and strategy for the service took into account the proposals made by NHS England. The clinical lead told us there was effective and regular communication with commissioners. In August 2017 there had been discussions regarding procurement for the next contracting period.
Learning, continuous improvement and innovation
A part of the service strategy was to implement the dental electronic referral system (DERS) to
replace the current paper format. There were plans to pilot paperless functionality in the
emergency dental service to improve efficiency as well as introduce text messaging appointment
reminders.
The service continued to work with the Public Health England and to carry out epidemiology
surveys when required.
Staff were given access to extra training and to take further qualifications to enhance the patient
experience and improve the services offered.
