Manor Surgery Limited

We carried out this announced focussed inspection 12 October 2021 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 Care Quality Commission, (CQC), inspector who was supported by a specialist dental adviser.

To get to the heart of patients’ experiences of care and treatment, we asked the following three questions:

• Is it safe?

• Is it effective?

• 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 this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

We found this practice was providing effective care in accordance with the relevant regulations.

Are services well-led?

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

Background

Manor Dental Surgery Limited is close to the centre of Sutton-in-Ashfield in north Nottinghamshire and provides NHS and private dental care and treatment for adults and children.

Car parking spaces, including dedicated parking for people with disabilities, are available near the practice.

The dental team includes five dentists, two dental hygiene therapists, six dental nurses including five trainees, the dental nurses also work on reception, two receptionists, and a practice manager. The practice has five treatment rooms, one of which is located on the ground floor.

The practice is owned by a company and as a condition of registration must have a person registered with the CQC 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.

At the time of inspection there was no registered manager in post as required as a condition of registration. A registered manager is legally responsible for the delivery of services for which the practice is registered.

During the inspection we spoke with dentists, dental nurses, receptionists 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 Friday: 8:15am to 5:15pm

Our key findings were:

• The practice appeared to be visibly clean and well-maintained.
• The provider had infection control procedures which reflected published guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
• The provider had systems to help them manage risk to patients and staff.
• The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• Improvements could be made to the system for monitoring hazardous substances used in the practice in line with the Control of Substances Hazardous to Health Regulations 2002.
• The provider had staff recruitment procedures which reflected current legislation.
• 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.
• Staff provided preventive care and supported patients to ensure better oral health.
• Improvements could be made to the governance systems at the practice.
• Staff felt involved and supported and worked as a team.

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

• Take action to ensure the regulated activities at Manor Surgery Limited are managed by an individual who is registered as a manager.

• 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.

• Take action to ensure a schedule of audits is developed, including radiography, infection prevention and control and dental care records, and undertaken at regular intervals to improve the quality of the service. The practice should also ensure where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.