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.

The provider had made some improvements to put right the shortfalls and had responded to some of the regulatory breach we found at our inspection on 23 April 2025. However, there was still aspects of the regulatory breach that had not been fully addressed. We have told the provider to take action. We will be following up on our concerns to ensure the provider has made the required improvements.

Although there are issues to be addressed, the impact of our concerns relates to the governance and the oversight of the risks, rather than a patient safety risk.

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.

At the inspection on 13 October 2025, we found the practice had made the following improvements to comply with the regulation:

The practice had taken steps to support effective governance and oversight, although there was still scope for improvement. A dental compliance system had recently been introduced at the practice. Staff were working to update information and fully implement systems and processes.

Policies updated onto the compliance system had been reviewed and reminders were set to ensure these were reviewed on a regular basis and updated as required.

There had been improvements regarding recruitment and staff training procedures, although improvements were required regarding oversight of staff training to ensure that all staff complete the required training. Not all staff had completed training regarding meeting the needs of people with a learning disability and autistic people or the role relating to the Mental Capacity Act. There was insufficient evidence available to demonstrate that the provider had completed the required amount of radiography training.

Recruitment files had recently been uploaded onto the newly introduced compliance system. The provider had systems in place to ensure that they could work in line with the recruitment policy. Most of the required pre-employment information was available for all staff. Hepatitis B immunity status was required for the trainee dental nurses.

There had been some improvements in the processes for identifying and managing some risks, a sharps and health and safety risk assessment had been developed. External professionals had completed both fire and legionella risk assessments. Action was outstanding to address the recommendations in both the fire and legionella risk assessments.

The legionella risk assessment identified the need to flush rarely used water outlets weekly and log to demonstrate action taken. Records were available to demonstrate that this task had been completed in May 2025 but there was no documentary evidence to demonstrate that rarely used outlets had been flushed since May 2025. There were no records to demonstrate that taps had been descaled in line with the recommendations from the risk assessment. Hot and cold water temperatures were being monitored and recorded. However, water was not at the required temperature on some occasions and there was no documentary evidence of action taken to rectify this.

There were numerous issues for action outstanding from the fire risk assessment completed on 29 May 2025. Some issues had been given a high priority for action. We were told that the fire alarm and emergency lighting had been serviced on 10 October 2025 although there was no documentation available to demonstrate this. The provider could not provide assurances that the servicing of this equipment had been completed by a person with relevant knowledge of fire safety systems.

Improvements were required to the oversight of medical emergency equipment checks. There was no portable suction available and the weekly medical emergency equipment did not identify that portable suction was missing.

There was scope for improvement regarding the oversight of the practice’s systems for appropriate and safe management of medicines as there was no stock control system in place. There was no log in place to monitor and track NHS prescriptions held at the practice.

Processes were now in place for investigating incidents and accidents, and for receiving and acting on safety alerts.

There had been some improvement with the practice’s systems and processes for learning, quality assurance and continuous improvement. The infection prevention and control audit was now being completed at the required frequency.

An antimicrobial prescribing audit had been completed.

A radiography audit and a patient record audit had been completed.

The practice had also made further improvements:

Clinical notes now contained written evidence recording why, at the patient’s request, the reason rubber dam was not used when required. However, clinical notes were not completed in line with national guidance. Handwriting on patient notes was difficult to read.

Evidence was not available in all records seen that the dentist justified, graded and reportedon the radiographs they took.

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.