MA Surgeries Ltd

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 accordance with the relevant regulations and had taken into consideration appropriate guidance.

The provider had made improvements in relation to the regulatory breach we found at our on-site inspection on 22 October 2025.

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.

At the focused follow-up inspection on 29 June 2026, we found the practice had made the following improvements to comply with the regulations:

Radiation protection local rules and practices reflected current IRR2017 standards.

Three yearly x-ray performance tests were available for all X-ray machines.

A blood spillage kit was available.

A bodily fluid spill kit was available.

The mercury spillage kit was available.

The sharps risk assessment reflected current practice.

Improvement should be made to the practice's processes to ensure that evidence to confirm that autoclave validation was carried out at appropriate intervals.

Evidence to confirm that the gas boiler had been serviced in the previous 12 months was available.
 

The fire alarm was tested by activating the manual call points in rotation. Improvement should be made to ensure that the call point tests were carried out weekly not monthly.

Evidence to confirm the fire alarm had been inspected in the previous 6 months was available.

Evidence to confirm the emergency lighting had been inspected in the previous 12 months was available.
 

COSHH safety date sheets were available for every substance used in the practice.

COSHH applicable substances were stored securely or their storage areas signed appropriately.

Improvement should be made to the practice's processes for the control of COSHH identified substances to ensure risk assessments are carried out for every substance hazardous to health used in the practice.
 

Glucagon was present in the emergency medicine kit.

Buccal Midazolam wasn't present in line with current guidance.

A child size self-inflating bag with facemask was present in the emergency medicine kit.

At the focused follow-up inspection on 29 June 2026, we found the practice had made the following improvements to comply with the regulations:

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

The practice had arrangements to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals.

Improvement should be made to ensure that safeguarding children and adults at risk training is carried out to the correct level appropriate for specific roles in the practice.

At the focused follow-up inspection on 29 June 2026, we found the practice had made the following improvements to comply with the regulations:

Local anaesthetics were stored appropriately to prevent cross contamination.

The clinical waste bin in the principal dentist’s treatment room was foot operated.

Pouched sterilised instrument were dated appropriately.

The treatment room daily cleaning checklist included all the tasks required to be carried out. Improvement should be made to ensure checklists are dated appropriately.

Nursing staff knew who their infection control lead was.

Appropriate solution was used to manually scrub instruments prior to sterilisation.

The magnifying light in the decontamination room was of an adequate size to perform inspection tasks.

Labelling of clean and dirty instrument boxes was clear to prevent confusion.

Clinical staff member’s footwear was appropriate.

A decontamination glove and brush changing frequency protocol was in place.

Hot water was available on the day of our visit.

Dental instruments were manually cleaned using the correct temperature of water.

We were told that returned dental lab work was disinfected prior to use.

Cleaning equipment colour coding protocols corresponded with the practice’s policy, guidance for staff use.

Flooring in the ground floor staff toilet was clean and contained appropriate washing facilities.

Improvement should be made to ensure the annual infection prevention and control statement is completed in full.

The premises were visibly clean, well maintained and free from clutter. Improvement should be made to ensure that oversight of environmental cleaning standards can be demonstrated.

Female sanitaryware disposal facilities were available in the practice.

 

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