Windmill Dental Surgery

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 they have been put right by the provider. The impact of our concerns, in terms of the safety of clinical care, is minor for patients using the service. Once the shortcomings have been put right the likelihood of them occurring in the future is low.

During our inspection of this key question, we found concerns relating to the safety of the premises, adequacy and availability of emergency equipment and medicines, recruitment and training, support and development of staff, and the infection prevention and control standards being followed at the practice.
This resulted in a breach of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
 

You can find more details of our concerns in the report 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.

There was scope for improvement regarding the processes in place to identify and manage risks. We asked for a copy of the practice's sharps risk assessment, this had not been completed. The health and safety risk assessment completed in January 2025 did not include a comprehensive assessment of the practice to identify risks and record mitigating actions to reduce risks. One of the risks identified had not been acted upon. Additionally, there was no fire risk assessment in place. While we were told that a Legionella risk assessment had been scheduled for 2 May 2025, it had not yet been carried out. As a result, we were not assured that risks were being effectively managed at the practice.

Emergency equipment and medicines were available although some of these were missing or out of date. We saw that the self-inflating bags for adult and child were out of date and there were no clear face masks. The adult and child oxygen face masks and spillage kits were out of date. There was only 1 x 10ml dose of adrenaline and the 21g needles were out of date. Glucagon was being stored in the fridge but the temperature of the fridge was not being monitored and logged. The provider could not be assured that this medicine was being stored in line with manufacturers recommendations.

There were no logs of checks completed on emergency medicines or equipment in accordance with national guidance. We were told that emergency medicines were checked monthly but logs were not kept.

Staff could access emergency medicines and equipment in a timely manner, however there was no signage in place to demonstrate where the automated external defibrillator or emergency oxygen was stored. Clear signage should be in place both as a visual prompt for staff and to inform emergency services.

We saw training certificates for all staff apart from the receptionist to demonstrate that staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. We were told that the receptionist had completed this training at another place of work, however there was no documentary evidence on the premises to demonstrate this. A dental nurse had completed on-line training regarding medical emergencies and had not completed any face to face or hands on training within the last few years as recommended by the General Dental Council (GDC) and the Resuscitation Council (UK).

Hazardous substances were labelled and stored safely. Control of substances hazardous to health (COSHH) risk assessments were brief and did not record all required information such as people affected and actions taken to mitigate risk. There were no safety data sheets available to staff. We could not be assured that COSHH risk assessments were available for each hazardous product on the premises.

We did not see satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions on all occasions.

There were limited systems in place for the management of fire safety. There was no fire risk assessment and we were told that the fire alarm and emergency lighting had not been subject to regular servicing and maintenance in line with legislation. We saw documentation to demonstrate that fire extinguishers received an annual service.

There were no safety checks completed such as weekly testing of the fire alarm, monthly testing of the emergency lighting, visual checks of fire extinguishers, fire exits and fire doors. At the time of inspection, fire exits were clear and signposted.

There was scope for improvement in the practice’s arrangements to ensure the safety of the X-ray equipment. There was no information regarding the Radiation Protection Advisor at the practice. The provider was unable to provide evidence that the practice had registered with the Health and Safety Executive regarding the use of X-rays (a requirement of the Ionising Radiation Regulations 2017 (IRR17)). Local rules seen recorded out of date information and referred to 1999 regulations and the provider was unable to find an up-to-date version. X-ray isolation switches within the practice were not labelled and staff were not aware of their location. There was no evidence of any radiography training for the provider since 2019. Rectangular collimators were not in use on all intra oral x-ray units. Rectangular collimators further reduce unnecessary radiation exposure to patients.

The practice’s systems for appropriate and safe management of medicines required improvement. Antibiotics were not securely stored and there was no stock control system or logs to demonstrate antibiotics given or stock available on the premises.

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. We noted that the practice were not working in accordance with this policy. At the point of employment, not all recruitment information in line with Schedule 3 of the Health and Social Care Act (Regulated Activity) Regulations 2014 was available for all staff.

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

There was no documentary evidence to demonstrate that newly appointed staff had an appropriate role specific structured induction. We were told that verbal instruction was given but that there was nothing in writing.

Staff told us that there were sufficient levels of staff on duty at all times.

There was no evidence to demonstrate that all staff had completed safeguarding training to the required level. Staff were unsure about ‘was not bought’ where a child was not bought to their appointment and its relevance to safeguarding. Staff were aware of how safeguarding information could be accessed but this was not freely available throughout the practice. Staff knew how to escalate safeguarding concerns within the practice.

The practice had some arrangements to ensure that staff training, including continuing professional development, was up-to-date and reviewed at the required intervals although improvements were required. There was no documented evidence that trainee dental nurses had completed any training whilst working at the practice. This included induction training. Safeguarding and radiography update training was overdue for completion by the provider and there was no evidence that they had completed training regarding mental capacity and interacting with people with a learning disability and autistic people.

There was no written evidence to demonstrate that staff formally discussed their training needs and aims for future professional development.

Staff stated they felt respected, supported and valued, and they were proud to work in the practice. Staff praised the management saying that they were caring and supportive.

There was limited oversight of infection prevention and control for example;

Local anaesthetic was not being stored in blister packs in surgeries.

The mercury spillage kit was in need of replacement and the bodily fluids spill kit was out of date.

There was evidence that qualified dental nurses and the provider received appropriate infection prevention and control training, there was no information available to demonstrate that the trainee dental nurses had received any such training. There was scope to improve staff knowledge and awareness of infection prevention and control processes.

Floor seals were coming away from the walls in the treatment room and in the decontamination room.

Drawers in the treatment room were visibly dirty and required cleaning, some instruments were kept in drawers un-pouched, whilst others were in pouches but these were not dated.

The sharps box in the surgery did not record a date of opening and had not been signed. The lid to the sharps bin was loose and came off when the bin was moved.

Laboratory work was not disinfected when received at the practice.

We observed use of personal protective equipment and the decontamination of used dental instruments, which did not align with national guidance. The dental nurses arms were not bare below the elbow and we observed them wearing the same gloves whilst moving throughout the practice including in the reception, waiting room and treatment room.

We noted that manual cleaning was completed using Hibiscrub under running water. (Hibiscrub can cause proteins to adhere to steel, making it difficult to clean instruments properly). The temperature of the water used in the manual cleaning process was not checked as instruments were cleaned under running water. There were no boxes for the transportation of dirty or clean instruments to and from the treatment room. The inspection light on the clean side was used for viewing dirty instruments. On the day of our inspection pouched instruments were placed on a non vacuum cycle in the autoclave.

There was scope for improvement to ensure that the practice had effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. There was no Legionella risk assessment in accordance with guidance and no evidence of water quality checks or flushing of dental unit water lines.

Improvements were required to the practice’s protocols to ensure safe segregation and disposal of hazardous waste. We saw that clinical waste bags were not labelled with the practice name and postcode. There were no cleaning schedules or logs in place to demonstrate effective cleaning of the practice. There was no information on display regarding the correct colour coded cleaning equipment to be used in the appropriate area. Staff were not aware of the correct colour coded equipment to use in the treatment room or other areas of the practice.

There was no surgery cleaning log to demonstrate tasks completed at the start of each session, in between patients and at the end of each session. There was no daily checklist for the decontamination room.

Not all equipment in use was maintained and serviced as per manufacturers’ instructions. Staff were not completing checks and keeping logs for the autoclave. Information from the data logger was being downloaded but this had not been done recently as the software was not working properly. There were no service or maintenance records for the ultrasonic cleaner in use (no soil/protein tests). There were no service or maintenance records for the washer disinfector. We were told that this equipment was not in use. There was no sign in place to demonstrate this or to prevent accidental use by staff.

The practice completed infection prevention and control audits but these were not completed at the frequency suggested in current guidance. The infection prevention and control audits seen had not identified the issues we observed during this inspection.

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