Updated 1 March 2024
We carried out this announced comprehensive inspection on 30 January 2024 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, we always ask the following 5 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:
- The dental clinic appeared clean and well-maintained.
- The practice did not have infection control procedures which reflected published guidance.
- Staff knew how to deal with medical emergencies. Most appropriate medicines and life-saving equipment were available.
- The practice had 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 did not have staff recruitment procedures which reflected current legislation.
- 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.
- Staff felt involved, supported and worked as a team.
- Complaints were dealt with positively and efficiently although recording of complaints required strengthening.
- The practice had information governance arrangements.
Background
Manor House Dental is in South Yardley, Birmingham and provides NHS and private dental care and treatment for adults and children.
The services are provided by 2 CQC registered providers at this location. This report only relates to the provision of general dental care provided by Manor House Dental, (Provider - Manor House Dental). An additional report is available in respect of the general dental care services which are registered under Manor House Dental, (Provider - Scandi Smile Centre Limited).
There is step free access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for people with disabilities, are available near the practice. The practice has made reasonable adjustments to support patients with access requirements.
The dental team includes 3 dentists, 4 dental nurses, 1 dental therapist, 1 practice manager and 3 receptionists. The practice has 3 treatment rooms.
During the inspection we spoke with 2 dentists, 3 dental nurses 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 from 8.30am to 5.30pm.
Tuesday from 8.30am to 5pm.
Wednesday from 8.30am to 12.30pm.
Thursday from 10.15am to 7.45pm.
Friday from 8.30am to 5.30pm.
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 regulation/s the provider was/is not meeting are at the end of this report.
There were areas where the provider could make improvements. They should:
- Take action to ensure the availability of equipment in the practice to manage medical emergencies taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council. Implement an effective system of checks of medical emergency equipment and medicines taking into account the guidelines issued by the Resuscitation Council (UK).
- Take action to ensure the clinicians take into account the guidance provided by the College of General Dentistry when completing dental care records.