Archived: Mr R K Desai - Water Eaton Health 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 providing safe care in line with the relevant regulations and had taken into consideration appropriate guidance.

Although there were 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 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 had processes to identify and manage risks. However, we found these were not always applied consistently or effectively, particularly in relation to risks associated with dental radiography, medical emergencies, medicines and prescriptions, and infection, prevention and control.

Systems for checking emergency equipment and medicines required strengthening as they had not identified that items of medical emergency kit were missing or out of date. We were assured items that were missing or were found to be out of date would be ordered immediately following our inspection. We were also assured weekly checklists would be implemented to ensure all items were present and expiry dates had not been exceeded.

Staff completed training in emergency resuscitation and basic life support; however, this was overdue as it was an annual requirement and last completed in December 2024. Training had been scheduled in March 2026.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely.

We saw satisfactory records of servicing and validation of most equipment in line with manufacturer’s instructions.

The practice had arrangements to ensure the safety of the X-ray equipment. However, there was no evidence that electromechanical servicing had been completed on X-ray equipment. This should be completed annually or at a frequency suggested in manufacturers recommendations. We also noted that local rules were out of date and required updating. 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.

Fire safety was managed by the health centre and NHS Property Services (NHSPS). We noted the Electrical Installation Condition Report (fixed wiring) had remedial recommendations for action. The provider was liaising with NHSPS to ensure recommendations were actioned. Fire exits were clear and well signposted.

The practice had systems for the management of medicines. NHS prescription pads and medicines were kept securely. Improvements were required to monitor and track their use.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff.

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

Staff had the skills and experience to carry out their roles. They told us that there were enough staff on duty at all times. They demonstrated knowledge of safeguarding and were aware of how safeguarding information could be accessed. Staff knew how to escalate safeguarding concerns within the practice and externally.

The practice put measures in place following our inspection to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals.

There were effective processes to support and develop staff with additional roles and responsibilities. Staff discussed their learning needs, general wellbeing and aims for future professional development during one-to-one meetings and ongoing informal discussions.

The practice had infection prevention and control procedures which required strengthening to reflect published guidance. There was scope to improve staff knowledge and awareness of infection prevention and control processes.

Staff used personal protective equipment and decontaminated dental instruments after use. We saw, and staff confirmed that single-use items were not reprocessed.

The practice had procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. There was scope to ensure these were in line with current guidance. An external Legionella risk assessment had been completed through NHSPS. However, the provider was unsure whether recommendations identified within the risk assessment had been completed. We were provided assurance they would be liaising with NHSPS to ensure actions were completed.

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste.

Equipment was maintained and serviced in line with manufacturers’ instructions.

The practice completed infection prevention and control audits. There was scope to ensure these were undertaken in line with current guidance.

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