Holywell House - Manor Dental

We carried out this announced comprehensive inspection on 28 November 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, 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 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 systems to manage risks for patients, staff, equipment and the premises. We identified minor shortfalls in assessing and mitigating risks in prescription management.
• Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The practice had 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.
• 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

Holywell House – Manor Dental is in Nuneaton, Warwickshire and provides NHS and private dental care and treatment for adults and children.

There is step free access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for disabled people, are available in the practice car park. The practice has made reasonable adjustments to support patients with access requirements.

The dental team includes 14 dentists, including 5 specialists, 20 dental nurses, including 3 trainee dental nurses, 1 dental hygienist, 1 dental therapist, 4 practice management staff and 6 receptionists. The practice has 4 treatment rooms.

During the inspection we spoke with 1 dentist, 3 dental nurses, (including 2 who were working on reception on the day of inspection) and 1 dental hygienist. We also spoke with 4 receptionists (including 2 who also work as dental nurses included above), the administration manager, the clinical lead, and the registered manager. All staff work across other locations owned by the provider. We spoke with a practice manager from another location owned by the provider who was present during this inspection. We looked at practice policies, procedures and other records to assess how the service is managed.

The practice is open:

Monday to Thursday from 9am to 6pm.

Friday from 9am to 5.30pm.

Saturday from 8am to 2pm.

The practice provides extended opening hours on some Tuesdays and Wednesdays.

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

• Improve the security of NHS prescription pads in the practice and ensure there are systems in place to track and monitor their use.