The Care Quality Commission
  • Dentist
  • Dentist

Manor Square Dental Practice

10 Manor Square Otley, Otley, West Yorkshire, LS21 3AP (01943) 461501

Provided and run by:
Dr. Paul Ellul

All Inspections

18 May 2022

During an inspection looking at part of the service

We undertook a follow up focused inspection of Manor Square Dental Practice on 18 May 2022. This inspection was carried out to review in detail the actions taken by the registered provider to improve the quality of care and to confirm that the practice was now meeting legal requirements.

The inspection was led by a CQC inspector who was supported by a specialist dental adviser.

We undertook a comprehensive inspection of Manor Square Dental Practice on 15 December 2021 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We found the registered provider was not providing safe care and was in breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can read our report of that inspection by selecting the 'all reports' link for Manor Square Dental Practice on our website www.cqc.org.uk.

When one or more of the five questions are not met, we require the service to make improvements and send us an action plan. We then inspect again after a reasonable interval, focusing on the area where improvement was required.

As part of this inspection we asked:

• Is it safe?

Our findings were:

Are services safe?

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

The provider had made improvements in relation to the regulatory breach we found at our inspection on 15 December 2021.

Background

Manor Square Dental Practice is in Otley to the north west of Leeds and provides NHS and private dental care and treatment for adults and children.

The practice has six treatment rooms, one of which is located on the ground floor. There are car parking spaces, including dedicated parking for people with disabilities, near the practice.

The dental team includes nine dentists, 14 dental nurses and four non-clinical members of staff.

During the inspection we spoke with dental nurses 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: 8:30am to 5pm.

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.

  • Improve the practice’s infection control procedures and protocols taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’. In particular ensure regular testing of the washer disinfector is carried out and recorded.

15 December 2021

During an inspection looking at part of the service

We carried out this announced focussed inspection 15 December 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 not 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 Square Dental Practice is in Otley to the north west of Leeds and provides NHS and private dental care and treatment for adults and children.

The practice has six treatment rooms, one of which is located on the ground floor. There are car parking spaces, including dedicated parking for people with disabilities, near the practice.

The dental team includes nine dentists, 14 dental nurses and four non-clinical members of staff.

The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.

During the inspection we spoke with dentists, dental nurses 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: 8:30am to 5pm.

Our key findings were:

  • The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • 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.
  • The appointment system took account of patients’ needs.
  • Staff felt involved and supported and worked as a team.
  • The provider had information governance arrangements.
  • Risks from the undertaking of regulated activities had not been suitably identified and mitigated.
  • The practice appeared to be visibly clean and well-maintained.
  • The provider had infection control procedures; however, they did not fully reflect national published guidance.
  • Staff knew how to deal with emergencies. The practice had emergency medicines and life-saving equipment; however, checks had failed to identify that some items were missing.
  • The provider had staff recruitment procedures which reflected current legislation; however, it was unknown if all staff had immunity to the Hepatitis B virus.
  • Improvements could be made to the quality assurance processes, particularly with regard to audits.

We identified regulations the provider was not complying with. They must:

  • Ensure care and treatment is provided in a safe way to patients

Full details of the regulations the provider 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 audits of radiography and infection prevention and control are undertaken at regular intervals to improve the quality of the service. Practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.

7 September 2016

During a routine inspection

We carried out an announced comprehensive inspection on 7 September 2016 to ask the practice the following key questions; are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

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

Are services effective?

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

Are services caring?

We found that this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

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

Are services well-led?

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

Background

The practice provides NHS treatment to adults and children patients with a small amount of private treatments in the Otley area and beyond.

The dental practice has six treatment rooms. There is a waiting/ reception area, two decontamination rooms, kitchen and staff room /office area. Off street parking is available adjacent to the practice.

The practice has six dentists, a dental therapist, five dental nurses, five trainee dental nurses, five receptionists and a practice manager.

The practice provides general dentistry and is actively involved in vocational foundation training for newly qualified dentists (foundation training enables newly qualified dentists to work within the National Health Service (NHS) system).

The practice is open Monday – Friday 8:30am- 5pm.

The principal dentist is registered with the Care Quality Commission (CQC) as an individual. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is run.

Before the inspection we sent CQC comment cards to the practice for patients to complete to tell us about their experience of the practice. We also talked with six patients. All the feedback we received was positive about the care and treatment received at the practice.

Our key findings were:

  • The practice appeared clean and hygienic and a patients we spoke with confirmed this.
  • The practice had procedures in place to record and analyse significant events and incidents.
  • The premises and equipment were secure and well maintained.
  • Staff had been trained to deal with medical emergencies, and emergency medicines and equipment were available.
  • Staff had received safeguarding training, knew how to recognise signs of abuse and how to report it. They had comprehensive systems in place to work closely and share information with the local safeguarding team.
  • There were sufficient numbers of suitably qualified and trained staff to meet the needs of patients.
  • Patients received clear explanations about their proposed treatment, costs, benefits and risks and were involved in making decisions about it.
  • We observed that patients were treated with kindness and respect by staff.
  • Staff ensured there was sufficient time to explain fully the care and treatment they were providing in a way patients understood.
  • Patients were able to make routine and emergency appointments when needed.
  • The practice had a complaints system in place and there was an openness and transparency in how these were dealt with.
  • Patient feedback was regularly sought and reflected upon.

There were areas where the provider could make improvements and should:

  • The provider had infection prevention and control procedures in place and staff followed current guidelines for the decontamination of equipment however some improvements were needed to ensure all areas met current guidelines.
  • Recruitment procedures were not always robust as not all recruitment documents were in place.

10 October 2012

During a routine inspection

People's privacy, dignity and independence were respected. We observed staff treating people with respect, being polite and courteous. There was a supportive atmosphere between staff and the people who used the service. One person told us, 'I listen to the advice given by the dentist then I make my own decision.' Another person told us, 'I have been given advice on flossing and brushing techniques.'

People experienced care, treatment and support that met their needs and protected their rights. We spoke with five people and they all told us they were happy with the care and treatment they received. One person told us, 'I cannot ask for anything better, they explain everything.' Another person told us, 'Staff are welcoming, I have no complaints and care is good.'

There were effective systems in place to reduce the risk and spread of infection. The people we spoke with told us that they had no concerns with the hygiene. One person said, 'I am happy with the hygiene, I would let them know if not.'

People were cared for, or supported by, suitably qualified, skilled and experienced staff. Appropriate checks had been undertaken before staff began work.

There was an effective complaints system in place. Complaints people made were responded to appropriately. People told us if they had any concerns or complaints they would discuss them with the provider or members of staff and they were confident of using the complaints system.