Bradley and Partners

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.

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.

Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. However, staff did not participate in medical emergency scenario training. We have received evidence since the inspection to demonstrate this training has been completed

Staff we spoke with told us that equipment and instruments were well maintained and readily available.

Emergency equipment and medicines were available and checked in accordance with national guidance. However, the oropharyngeal airways had expired, the weekly check sheet had been recorded as “out of date” for a number of weeks. Since the inspection we have received evidence the equipment has been replaced.

The premises were not all visibly clean, well maintained or free from clutter. There was evidence of a persistent damp issue, peeling wallpaper and paint in various areas within the practice. In addition, we saw clutter and rubbish, including expired equipment in one of the unused treatment rooms, staff areas and the basement. The carpets were worn, torn and ripped in areas of the practice We have received evidence since the inspection the damp areas have been treated

Hazardous substances were clearly labelled and stored safely.

We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. However, the servicing information for the compressor was not available

The practice ensured equipment was safe to use and maintained and serviced according to

manufacturers’ instructions with the exception of the compressor. The practice did not ensure all

the facilities were maintained in accordance with regulations.

The management of fire safety was effective. We did see documentary evidence of the

servicing of the emergency lighting, and fire equipment, However, weekly checks of the fire

alarm, monthly checks of the emergency lighting and housekeeping arrangements had not been

conducted for some time. The fire risk assessment conducted in September 2024 had actioned

the fitting of fire doors throughout the practice, this had not been completed. Fire safety training

had lapsed for some members of staff or not completed at all. Signage indicating exit routes

were not available in some areas.

No fire drills had been conducted. Since the inspection we

have received evidence the training had been completed, A fire log book was sent to us showing regular checks of the alarm and emergency lighting had been carried out, two new call points had been installed and further signage purchased.

The practice had arrangements to ensure the safety of the X-ray equipment required radiation

protection information was available. This included cone-beam computed tomography (CBCT).

However, we found the sliding door to the CBCT room was loose, broken, unsecurable and did

not offer the operator sufficient protection during an exposure as there was a large gap at the

bottom of the door

The practice had risk assessments to minimise the risk that could be caused from substances

that are hazardous to health.

The practice had ineffective systems to assess, monitor and manage risks to patient and staff

safety. The most recent health and safety risk assessment conducted by an external contractor

had actioned the need for an asbestos risk assessment. This was not made available to us.

The practice had systems for appropriate and safe handling of medicines. We saw local

anaesthetic cartridges were prematurely removed from their protective blister packs and stored

loose in drawers. This poses a risk of contamination of the diaphragm. Since the inspection we

have been assured this had been addressed.

We found many expired dental materials in the treatment rooms. Since the inspection we have

received evidence these have been disposed of.

Antimicrobial prescribing audits were not carried out. We were sent evidence of an antimicrobial prescribing audit following our inspection.

The practice had a recruitment policy and procedures to help them employ suitable staff, including agency or locum staff. These reflected relevant legislation but were not always being followed. Information relevant to staff employment in their role as required under Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was not always available. For example, a Disclosure and Barring Service (DBS) check, and evidence of Hepatitis B immunity (titre levels) was not available for 2 staff members and there was no risk assessment in place. Satisfactory evidence of conduct in previous employment was not seen for any of the staff records we reviewed.

Newly appointed staff had not all had an appropriate role specific structured induction.

Staff we spoke with could not demonstrate they had the skills, knowledge and experience to carry out their roles. Although there were enough staff on duty,

The practice has provided assurance that all of the required records relating to recruitment are now in place.

The practice did not have arrangements to ensure staff training, including continuing professional development (CPD), was up-to-date and reviewed at the required intervals. Not all clinical staff were able to demonstrate that they had undertaken all CPD relevant to their roles as recommended by the General Dental Council (GDC). We saw gaps in the following topics: fire safety, safeguarding adults and children, infection, prevention and control (IPC), Interacting with People with a Learning Disability and Autistic People, Legionella, legal and ethical, Mental Capacity Act, Sepsis and complaints handling. Following the inspection, we have been provided evidence this shortfall has been rectified.

Staff demonstrated knowledge of safeguarding but were not aware of how safeguarding information could be accessed. Staff knew how to escalate safeguarding concerns within the practice but did not have current information on how to escalate concerns externally, however, the three safeguarding referrals we reviewed had followed the correct process. Following our inspection we were assured information was available throughout the practice for all staff.

The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover. Although one staff member indemnity cover had expired. Since the inspection we have been advised this shortfall has been rectified.

The practice appeared clean in some areas, we saw visible dirt and dust in some of the treatment rooms and the decontamination room, There were no cleaning schedules used to ensure effective and thorough cleaning of the practice on a regular basis. Following our inspection we received evidence a new environmental cleaner had been recruited, the areas of concern had been added to the regular cleaning schedules and a customer review form given to the practice to identify any areas that were missed to ensure the environment was cleaned sufficiently.

Staff followed infection control principles, including the use of personal protective equipment (PPE).

Hazardous waste was segregated and disposed of safely.

The practice had infection control procedures that reflected published guidance, but these were not always being followed.

Staff were aware of infection prevention and control processes but had not received appropriate training and could not demonstrate a sufficient knowledge of these. Since the inspection we have been informed this training is now up to date.

The decontamination of used dental instruments, which did not wholly align with national guidance. For example, a thermometer was not used to ensure the enzymatic detergent used for manual cleaning was within the appropriate range. Since the inspection we have been informed the enzymatic detergent has been replaced with one that does not require temperature monitoring.

We witnessed staff rinsing instruments post scrubbing under a running tap, this causes an aerosol which poses a recontamination risk. Since the inspection we have received evidence that this shortfall has now been addressed.

In addition, we did not see consistent records to demonstrate that weekly and daily testing on the equipment were being completed in line with manufacturer`s instructions or current guidance. Instruments including X-ray holders, hand scalers and burs, kept in clinical areas, were not always pouched and some were pouched but undated. The transportation boxes for dirty instruments were visibly dirty and not subject to regular cleaning or disinfection. We have received evidence that the boxes have been replaced since the inspection.

The practice had effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. A risk assessment had not been completed in line with current guidance; water temperature monitoring of the sentinel taps was not carried out. we were sent a risk assessment that had been conducted following our inspection and logs for the water temperature monitoring and flushing of the taps and shower.

No audits of infection prevention and control were carried out. we were sent a infection prevention and control audit following our inspection staff ensured these were now conducted every six months as per HTM01 05 Guidance.

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