Broadway Dental Practice

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We found this practice was providing safe care in accordance with the relevant regulations and had taken into consideration appropriate guidance.

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

The judgement for Learning culture is based on the latest evidence we assessed for the Safe key question.

The judgement for Safe systems, pathways and transitions is based on the latest evidence we assessed for the Safe key question.

The judgement for Safeguarding is based on the latest evidence we assessed for the Safe key question.

The judgement for Involving people to manage risks is based on the latest evidence we assessed for the Safe key question.

The practice had processes to identify and manage risks and staff we spoke with were able to describe these to us. Staff demonstrated an open culture in relation to people’s safety. Staff felt confident that risks were well managed at the practice, and this was reflected in our findings.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely.

Most emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. Staff were also encouraged to participate in medical emergency scenario training.

However, systems of oversight to ensure availability of emergency equipment and medicines in line with relevant guidance were not always working effectively. We noted on the day of assessment that the dosage and form of the aspirin available was not in line with the Resuscitation Council UK national guidance and that the spacer for the salbutamol and the oropharyngeal airways (sizes 0,1,2,3,4) were not available. The practice acted immediately and purchased the required aspirin on the day of assessment and sent evidence following the assessment that the spacer and airways had been ordered.

We saw satisfactory records of servicing and validation of most equipment in line with manufacturer’s instructions. We noted the Orthopantomograph (OPG) X-ray machine (a specialised X-ray machine used in dentistry to create a panoramic wide view image of the jaws, teeth and surrounding structures) was overdue a 3-yearly routine performance test. The practice acted immediately and submitted evidence following the assessment this had been booked for 17 March 2025.

The management of fire safety was not always effective. Fire exits were clear and well signposted, and a fire risk assessment had been completed. However, we were not assured the risk assessment had been undertaken by a competent person and we identified a few minor omissions. Staff told us they had been testing smoke alarms weekly and visual inspection of fire extinguishers monthly, but they had not been recording these checks and therefore, had no process of oversight to ensure these were being done routinely. The provider confirmed following the assessment that they had booked a fire safety risk assessment for 17 March 2025 and had implemented a new checklist to record in-house fire equipment testing.

NHS prescription pads were mostly stored securely, there was a log in place to monitor and track their use and antimicrobial prescribing audits were carried out. However, on the day of assessment, we noted 2 NHS prescription pads were pre-stamped with prescriber authorisation, which increased the risk of them being taken or used inappropriately by unauthorised persons. We discussed this with the provider and were assured this would be addressed urgently.

The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover.

Newly appointed staff had an appropriate role specific structured induction.

Staff we spoke with had the skills, knowledge and experience to carry out their roles. They told us that there were sufficient levels of staff on duty at all times. They demonstrated knowledge of safeguarding and were aware of how safeguarding information could be accessed. Staff knew how to escalate safeguarding concerns within the practice and externally.

The practice had arrangements to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals.

There were effective processes to support and develop staff with additional roles and responsibilities. Staff discussed their learning needs, general wellbeing and aims for future professional development during annual appraisals, practice team meetings and ongoing informal discussions.

Staff stated they felt respected, supported and valued, and they were proud to work in the practice.

The practice had a recruitment policy and procedures that reflected relevant legislation. However, we noted these were not consistently followed. We checked 6 staff files and noted that disclosure and barring service (DBS) checks had not been conducted by the practice at the time of recruitment for 3 staff members. Hepatitis B titres levels (to check the immunity to the virus) were not obtained for 2 clinical staff members. The provider acted immediately to risk assess these individuals and have assured us that all future recruitment will be in line with legislation.

The practice had infection control procedures that reflected published guidance.

Staff received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes.

We observed use of personal protective equipment and the decontamination of used dental instruments, which aligned with national guidance. We saw, and staff confirmed that single use items were not reprocessed.

The practice had effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance.

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste.

The equipment in use was maintained and serviced as per manufacturers’ instructions.

The practice completed infection prevention and control audits. However, we noted these were being completed annually rather than every 6 months in line with national guidance. We discussed this with staff and were assured this would be addressed.

The judgement for Medicines optimisation is based on the latest evidence we assessed for the Safe key question.