Manor Dental Practice

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We found this practice was providing well-led care in accordance with the relevant regulations and had taken into consideration appropriate guidance. However at the time of the inspection, there was no registered manager in post as required as a condition of registration. A registered manager is legally responsible for the management of services for which the practice is registered.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The judgement for Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis.

Systems and processes were embedded, and the inspection did not highlight any issues or omissions.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records, and paper records were stored securely and complied with General Data Protection Regulations. Electronic devices were used for patients to complete documents, for example their consent forms and medical histories.

Relevant policies and protocols were in place for the use of closed-circuit television (CCTV).

There were effective processes for identifying and managing risks, investigating incidents and accidents, and for receiving and acting on safety alerts.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

Staff had clear responsibilities, and systems of accountability to support good governance.However, at the time of the inspection, the practice did not have a CQC registered manager in post as required by the Care Quality Commission (Registration) Regulations 2009. Upon being made aware that there was no CQC Registered Manager in place, the Practice Manager promptly created an incident report and immediately initiated the application process to ensure a Registered Manager is appointed as soon as practicably possible.

Staff feedback was obtained through meetings, surveys, and informal discussions. They were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. For example, based on patient feedback, the practice used an electronic device for patients to complete medical history forms on.

The practice had taken steps to improve environmental sustainability. For example, the practice was working towards becoming paperless and used an online compliance system. Practice staff recycled all paper and cardboard and the use of an electronic device for recording dental records cut down on waste material. Staff also car shared when attending bi-annual meetings.

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.