During an assessment under our new approach
Date of Assessment: 13 October and 16 October 2025. Dalton Surgery is a GP practice and delivers services to approximately 7,000 patients under a contract held with NHS England.
Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the fourth decile (4 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
We assessed this practice due to information of concern we received and the length of time since our last inspection. The assessment was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential risk of ongoing harm.
This was an announced assessment looking at all the quality statements and all key questions. We have rated the practice as requires improvement overall. The key question of well-led is rated as inadequate, the key questions of safe, effective and responsive are rated as requires improvement and the key question of caring is rated as good.
Safe: We looked for evidence that people were protected from abuse and avoidable harm. Leaders told us that they promoted a culture of learning and staff told us they could raise concerns. However, we found gaps in systems and processes around safeguarding, safe environments, safe and effective staffing, infection prevention and control and medicines management which could potentially impact on patient safety.
Effective: We looked for evidence that staff involved people in decisions about their care and treatment and provided them with advice and support. Although staff regularly reviewed people’s care and worked with other services to achieve this, the management of some patients with long-term conditions was not always in line with guidance. There was limited quality improvement activity, including clinical audits, to drive patient outcomes.
Caring: We looked for evidence that the practice involved people and treated them with compassion, kindness, dignity and respect. Staff demonstrated how they protected patient privacy and dignity, treated patients as individuals and supported their preferences. Feedback through the NHS Friends and Family Test (FFT) and the most recent National GP Patient Survey was positive and demonstrated patients felt listened to, supported, and involved in decisions about their care. The practice supported staff wellbeing.
Responsive: We looked for evidence that the service met patient’s needs, and that staff treated people equally and without discrimination. We found patients were able to access suitable appointments, based on clinical need. However, the findings of our clinical notes review impacted on responsive care as we found follow-up care was not in line with guidance. The practice was in the process of reviewing and refining systems to ensure vulnerable people or those with protected characteristics could access care and treatment in ways that met their personal circumstances. We found gaps in systems and processes around complaints management. Patient feedback in the National GP Patient Survey (2025) and the NHS Friends and Family Test (FFT) was positive about the practice.
Well-Led: We looked for evidence that the practice’s leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. Although the practice had an overarching governance framework, we found gaps in its management and oversight which meant systems and processes were not operating effectively. In particular, we found concerns around safeguarding, safe environments, safe and effective staffing, infection prevention and control, medicines management and the management of patients with long-term conditions. There was limited quality improvement activity, including clinical audits, to drive patient outcomes. There were no well-defined and embedded vision, values and strategy, written in collaboration with staff, people who use the service and external partners.
We found a breach of regulation in relation to Regulation 17 – Good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.