Broadway Dental Centre

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 accordance with the relevant regulations.

We will be following up on our concerns to ensure the provider has made the required improvements.

During our inspection of this key question, we found concerns related to:

the safety of the premises and equipment,

safe and effective staffing,

infection prevention and control standards,

staff’s understanding, knowledge and awareness of the management of medical emergencies.

These concerns resulted in breaches of Regulations 12 (Safe care and treatment) and 15 (Premises and Equipment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can find more details of our concerns in the detailed findings below.

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 did not have effective systems to identify and manage risks.

No medical emergency medicines or equipment were available within the practice. Furthermore, the practice did not have access to an Automated External Defibrillator (AED), a mercury spillage kit or a bodily fluid spillage kit.

There were no records to demonstrate that they had completed training in emergency resuscitation and basic life support.

We were not assured that the practice had effective medical emergency management procedures or that staff were competent in dealing with medical emergencies.

There were no records to demonstrate that the autoclave and compressor had been serviced, validated and maintained appropriately.

The practice did not have effective systems in place for the safe use of radiography equipment. We do not assess compliance with the Ionising Radiation regulations 2017 and the Ionising Radiation (Medical Exposure) regulations 2017, but we do request services to provide evidence that demonstrates their compliance to inform our findings. On the day of inspection, there were no records in relation to the safe use of X-ray equipment such as an installation and acceptance test, routine performance testing and evidence of a Radiation Protection Advisor being available.

On the day of inspection there were no risk assessments or material safety data sheets for substances which are hazardous to health.

The management of fire was not effective, there was no fire risk assessment in place, no record of fire drills or testing of the fire detection equipment. The practice had 4 fire extinguishers however there was no evidence that these had been serviced. The practice also had no emergency lighting.

1 of the 2 fire exits were blocked and the lock was broken making it inaccessible as an escape route. When asked, staff admitted to having had no fire training.

The practice did not ensure the facilities were maintained in accordance with regulations. There were no records to demonstrate that an electrical installation condition report (EICR) had been carried out on the premises to ensure the electrical wiring was safe.

The premises were not visibly clean nor well maintained, there was a hole in the floor of the decontamination room, cables trailing throughout the practice and multiple trip hazards.

NHS prescription pads were not kept securely and there was no log to track their use.

The practice did not have suitable recruitment procedures in place nor effective systems to ensure staff training were up to date and reviewed at required intervals. On the day of inspection staff were unable to produce any evidence of recruitment documents as required under Schedule 3 of the Health and Social Care Act2008 (Regulated Activities) Regulations 2014. In addition, there was no evidence of any training certificates for any member of staff.

We saw that surfaces in all surgeries and the decontamination room were not impervious or easily cleanable. We saw that cleaning mops and buckets were not stored appropriately to prevent cross contamination between surfaces.

We saw dental cement residue on some of the instruments which staff told us had been sterilised. There were no records showing in-house validation of the autoclave were being done. The decontamination room did not have a clear dirty‑to‑clean workflow or a suitable place for sterilised instrument trays. Staff were also washing mugs and cutlery in the same sink used to manually scrub contaminated dental instruments. There was also no access to hand soap or handwash in the practice.

There was no infection prevention and control audit available. The dental chair in surgery 1 was held together by tape. There was no evidence that dipslide tests were being undertaken on the waterline in the dental chair, on the inspection we saw a dirty biofilm appear.

The practice did not have protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste. Hazardous waste was not bagged appropriately and stored outside of the practice which was accessible to the public.

The management of the risks associated with Legionella was not effective. There was no legionella risk assessment and no evidence of water temperature testing or management of dental unit water lines.

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