Genix Healthcare Dental Clinic - Cirencester

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. The provider had made improvements in relation to the regulatory breach we found at our inspection on 24 November 2023.

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.

Staff showed us that the medical emergency medicines and equipment were available, in working order and in date. The medicine to treat low-blood sugar (Glucagon) was no longer stored in the medicines fridge, however, we saw the fridge temperature was being monitored. We saw the cleaning equipment was stored in accordance with guidelines and cleaning schedules were being completed. We saw the improvements that had been made to the oversight of infection control protocols to ensure staff adhered to them consistently. Internal fire checks were carried out consistently and fire drills were carried out regularly. Staff told us incidents and accidents were recorded, reviewed and used as an opportunity for shared learning. Staff described the protocols for the handling and disposal of dental sharps. Staff told us they felt comfortable accessing important, accurate information and policies. They knew who to contact to seek advice and were happy to raise concerns. Staff told us a system had been introduced to monitor referrals to ensure patients were seen in a timely manner. Staff showed us how staff training was monitored to ensure this was undertaken at the required interval and records were available for review. From the documents we were shown, we saw records were not available for all team members, including for hands-on basic life support (BLS) and Ionising Radiation (Medical Exposure) Regulations (IRMER) training. We were told hands on BLS training was booked for the week after the inspection and received confirmation following the inspection that additional training had also been undertaken in other topics. From the records we were shown, we noted the audits had documented learning points and the resulting improvements could be demonstrated. We discussed some further changes could be made to the radiography auditing process to ensure the recommended quantity and frequency of records assessed is in accordance with current guidance.

Records were available to demonstrate the risks identified relating to radiation protection had been addressed and mitigated. The practice had procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment. We were shown monthly water temperature monitoring records that indicated outlets fitted with thermostatic mixer valves, consistently had temperatures in excess of recommended levels. No action had been taken to address this. Improvements should be made to ensure prompt action was taken to address any risks identified. On the day of the assessment we tested the hot water temperatures at a number of outlets and noted temperatures were not reaching the minimum recommended temperature. The temperature monitoring records we were shown had not identified this risk; we could therefore not be assured of the accuracy of the records. In addition, we noted that while there was a protocol in place for flushing the dental unit waterlines (DUWLs); the product used to maintain them was not being used according to the manufacturer’s guidance to ensure its efficacy. Systems had been improved to ensure all equipment was serviced and maintained according to manufacturer’s guidelines, with the exception of the water heaters. The practice manager confirmed they would seek advice as to whether a servicing regime was required, particularly due to the concerns noted in relation to the hot water temperatures. We received confirmation following the inspection that these would be serviced. Substances hazardous to health were stored securely. Improvements had been made to the recruitment protocols to ensure checks were carried out effectively. Clinical staff had received appropriate vaccinations, including the vaccination to protect them against the Hepatitis B virus.

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.