We carried out a comprehensive inspection of this practice on 14 September 2015. Breaches of legal requirements were found. After the inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to good governance.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Genix Healthcare - Beeston on our website at www.cqc.org.uk.

Our findings were:

Are services well-led?

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

Background

Genix Healthcare - Beeston is situated in the Beeston area of Leeds. It offers mainly NHS treatment to patients of all ages but also offers private dental treatments. The services provided included routine restorative dental care, preventative advice and treatment.

The practice has four surgeries, a decontamination room, a waiting area, a reception area and disabled toilet facilities. Treatment and waiting rooms are on the ground floor of the premises.

There are four dentists, a dental hygienist, four dental nurses, two receptionists and a practice manager. They are supported by an area manager and a compliance lead.

The opening hours are Monday, Tuesday and Thursday 8-30am to 5-30pm, Wednesday 8-30am to 6-30pm, Friday 8-30am to 4-00pm and Saturday 9-00am to 3-00pm.

The practice manager is currently applying to be the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. 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.

Our key findings:

• The practice now had an effective system of audit in place and improvements could be demonstrated.
• Dental care records followed the guidance from the Faculty of General Dental Practice (FGDP).

We carried out an announced comprehensive inspection on 14 September 2015 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 not providing well-led care in accordance with the relevant regulations

Background

Genix Healthcare - Beeston is situated in the Beeston area of Leeds. It offers mainly NHS treatment to patients of all ages but also offers private dental treatments. The services provided included routine restorative dental care, preventative advice and treatment.

The practice has four surgeries, a decontamination room, a waiting area, a reception area and disabled toilet facilities. Treatment and waiting rooms are on the ground floor of the premises.

There are currently three full-time dentists, a part-time dentist, a dental hygiene / therapist, six dental nurses who also cover reception duties and a practice manager.

The opening hours are Monday, Tuesday and Thursday 8-30am to 5-30pm, Wednesday 8-30am to 6-30pm, Friday 8-30am to 4-00pm and Saturday 9-00am to 3-00pm.

The practice manager is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. 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.

During the inspection we spoke with three patients who used the service and reviewed 13 completed CQC comment cards. The patients who provided feedback were generally positive about the care and treatment they received at the practice; however some were unhappy about the lack of continuation of care due to frequent changes of dentists. They told us they were involved in all aspects of their care and found the staff to be friendly and helpful and they were treated with dignity and respect.

Our key findings were:

• The practice had systems in place to assess and manage risks to patients and staff including infection prevention and control, health and safety and the management of medical emergencies.
• Patients were treated with care, respect and dignity.
• There were clearly defined leadership roles within the practice and staff told us that they felt supported, appreciated and comfortable to raise concerns or make suggestions. Staff received training appropriate to their roles.

We identified regulations that were not being met and the provider must:

• Review the practice's protocols for completion of dental records giving due regard to guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.
• Ensure all audits have a documented action plan with guidance on improvements required and timescales for review.

You can see full details of the regulations not being met at the end of this report.

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

• Review the practice’s infection control procedures and protocols giving due regard to guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’.
• Review the practice’s protocols and procedures for promoting the maintenance of good oral health giving due regard to guidelines issued by the Department of Health publication ‘Delivering better oral health: an evidence-based toolkit for prevention’.

We spoke with two people who used the service and they said they were happy with the care and treatment they had received at the dental practice. People said the dentist had explained the care and treatment choices available to them. Everyone we spoke with said they did not have any concerns about the practice. One person said "I have been coming here for years" "I have recommended the practice to all my family". Another said, "the surgery is very clean" and said that "the dentist was very clear about the treatment choices, I have been given lots of information". People told us that the staff were very friendly and they had no problems getting an appointment. A person said "they always deal with you sensitively".

We spoke with four staff members who were very complimentary about the practice. One person said "I have worked here a long time". Another person said "everybody supports each other" All staff members said that they were very happy with the cleanliness of the practice.