Windmill Dental Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We found this practice was not providing well-led 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 the registered person had ineffective systems or processes that failed to enable them to assess, monitor and improve the quality and safety of the services being provided. We also found concerns around the effectiveness of the systems or processes to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk.

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 evidence category 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 Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

Systems and processes to support effective governance and oversight were not embedded. We were told that areas requiring improvement would be acted upon but we had not received evidence of this at the time of writing this report.

There was scope for improvement to the practice’s governance system. During the inspection, information and evidence was not always available. We also noted that staff were not working in accordance with some of the practice policies, for example the recruitment policy. Evidence was not available to demonstrate that policies were reviewed on a regular basis and we found that these were not always effective in ensuring governance, oversight and risk mitigation tasks were completed in line with guidance.

Recruitment files were available on the premises; however, the provider was not working in accordance with their recruitment policy as not all of the required pre-employment information was available for all staff.

Oversight of some procedures for example, recruitment and completion of staff training were not effective.

The practice had information governance arrangements and staff were aware of the importance of protecting patients’ personal information.

We saw there were some processes for identifying and managing some risks, although there was no sharps, fire safety or Legionella risk assessments. A Legionella risk assessment was booked for 2 May 2025. There were no processes for investigating incidents and accidents, and for receiving and acting on safety alerts.

The provider confirmed that they had received 1 formal complaint within the past few years which had been directed to NHS England and had been investigated and finalised. We were told that staff would discuss outcomes to share learning and improve the service as needed.

There was scope for improvement with the practice’s systems and processes for learning, quality assurance and continuous improvement. The infection prevention and control audit was not completed at the required frequency and did not highlight any of the issues identified during this inspection. There was no antimicrobial prescribing audit. The radiography audit had not been fully completed. There was no report or action plan, this audit was not completed at the required frequency. The patient record audit had not been fully completed as there was no report and no action plan.

Staff feedback was obtained through informal discussions and ad hoc formalised practice meetings. There was no system of staff appraisal. Formal practice meetings were held approximately every 3 months and we were told that informal meetings were held regularly.

Feedback from patients was obtained either verbally or there was a suggestions box in the waiting area. The practice did not respond to online reviews.

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.