Guiseley Partnership

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 not providing safe care in line with the relevant regulations and had taken into consideration appropriate guidance.

This resulted in a breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We will be following up on our concerns to ensure the provider has made the required improvements.Whilst there are issues to be addressed, the impact of our concerns relates to the governance and oversight of risks posed by the building, rather than clinical risk to patients.

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 identified risks effectively and staff described the processes in place to do this. This included sharps safety, sepsis awareness and lone working.

Clinically, the practice was providing safe care and treatment.

In relation to the premises, we found the provider was not supporting a safe environment for all patients to be seen in, or for staff to be working in.

Remedial works identified as being required in the premises, including those highlighted in the fire risk assessment dated August 11 2025, and the EICR (Electrical Installation Condition Report) from October 2025 which rated the condition of the installation as ‘Unsatisfactory’ had not been completed. On the day of this inspection, we saw communications from the provider’s property management department setting out proposed advance dates for completion of works to the electrical installation. No dates had been confirmed for the completion of the works identified in the fire risk assessment report. These delays meant the staff and practice manager were not confident that some risks in the practice were being effectively managed.

Staff could access emergency equipment and medicines that were checked in line with national guidance. They knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

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

We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions.

The practice had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available.

The practice had systems for appropriate and safe management of medicines. NHS prescription pads were kept securely, and a log was in place to monitor and track their use.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff. When we checked staff records that were available, we saw that not all checks were applied consistently. Overall, we found that compliance systems in place did not identify when some checks were missing or when risk assessments had not been completed. This was the case for recent use of locum staff, and for some members of permanent staff. We brought the examples we found to the attention of the provider.

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 had the skills, knowledge and experience to carry out their roles. They told us that there were enough 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 systems in place to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. However, there were gaps in this which demonstrated that the compliance systems used at practice and group level, were not effective. We have brought this to the attention of the provider.

There were processes to support and develop staff with additional roles and responsibilities. We identified areas where this was not working as it should and this was raised in our feedback to the provider.

Staff discussed their learning needs, general wellbeing and aims for future professional development during annual appraisals, at practice team meetings and in ongoing informal discussions. Staff were happy to work in the practice.

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.

Staff used personal protective equipment and decontaminated dental instruments after use, in line with national guidance. We saw, and staff confirmed that single-use items were not reprocessed.

The practice had procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance. However, records held to support these procedures demonstrated that water temperature checks had been missed for two periods, one in 2025 and one in 2026. It was not established why this had happened. Also, staff were not checking for the correct temperatures for the type of hot water system in the practice. This demonstrated that staff lacked understanding of the water monitoring requirements for the system in place and highlighted weaknesses in training, competency assessment and management oversight.

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

Equipment was maintained and serviced in line with manufacturers’ instructions.

The practice completed infection prevention and control audits in line with current guidance.

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