Dr Peter Tsakpo

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 insufficient improvements to put right the shortfalls of the regulatory breach we found at our inspections on 5 April 2022 and 3 August 2023. 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. 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.

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 16 May 2025, we found that this practice was not providing well-led care.

Whilst the provider demonstrated some improvements had been made, they had taken insufficient action to comply with the regulatory breach we found at our inspections on 5 April 2022 and 3 August 2023.

Although the recruitment policy reflected relevant legislation, they were not operated effectively to ensure that appropriate checks were carried out before the start of employment, and to maintain up-to-date staff records. In addition, the infection prevention and control policy included procedures to follow in relation to vaccination and immunity checks for clinical staff, but these were also not followed.

The practice did not ensure that clinical staff had current appropriate professional indemnity cover in place.

Right to work checks had not been updated for 1 member of staff who required this.

Disclosure and Barring Service (DBS) checks had not been actioned at the point of employment for 3 staff members.

The provider did not ensure they obtained evidence of occupational health clearance for Exposure Prone Procedures (EPPs) that were applicable, or the effectiveness of vaccinations against Hepatitis B for 3 clinical staff members in line with their policy. Where staff were identified as low responders to the vaccine, this was not risk assessed.

The provider did not have oversight of systems for prescribing of antimicrobial medicines in line with current guidance. Staff were not aware of current prescribing guidelines. There was no evidence the dentist (authorised to prescribe prescription-only medicines) had oversight and involvement in the prescribing of antimicrobials by unauthorised clinicians.

The practice had made the following improvements to comply with the regulation:

The practice had infection control procedures that reflected published guidance. Staff received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes.

The practice had arrangements to ensure the safety of the X-ray equipment, and the required radiation protection information was available to staff.

There were effective processes for documenting, investigating and learning from incidents.

The practice had systems and processes for learning and quality assurance. This included undertaking audits according to recognised guidance. We noted the detail documented in patient care records had improved since our previous inspections.

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.