Dalton Surgery

Date of Assessment: 17 June 2026 to 30 June 2026. Dalton Surgery is a GP practice which delivers services to around 7,100 patients under a contract held with NHS England. The practice operates from 364a Wakefield Road, Dalton, Huddersfield, West Yorkshire, HD5 8DY. The National General Practice Profiles states that the ethnic make-up of the practice is approximately 78% White, 9% Asian, 5.5% Mixed, 5.5% Black and 2% Other. Information published by the Office for Health Improvement and Disparities shows deprivation within the service population group is in the 4th decile (4 of 10). The lower the decile, the more deprived the service 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.

This assessment was prompted by a previous assessment which was undertaken in 2025, following which the practice rated as requires improvement overall, with well-led being rated as inadequate. In addition, during the assessment undertaken in 2025 the practice was found to be in breach of Regulation 17 Good governance of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This assessment was also used to evaluate the progress made by the practice in respect of an incident of concern which was received by the Care Quality Commission, and which was subsequently investigated by us and other stakeholders.

The practice had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. Systems were in place to manage referrals and joint working with health and care partners. However, it was noted that the practice had some backlogs related to the summarising of patient records and incoming correspondence which it planned to tackle. The facilities and equipment within the practice met the needs of people, were clean and well-maintained and any risks associated with it were mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Overall, staff managed medicines well, and involved people in planning any changes, although we identified some areas of medicines optimisation where the practice needed to make improvement.

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. However, there were some areas of service delivery where the practice needed to make improvement such as care for asthma patients, and cervical screening performance. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people and took decisions in people’s best interests where they did not have capacity.

People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated patients as individuals and supported their preferences, and adjustments were made, when possible, to effectively meet their individual needs and requirements. People had choice in their care and treatment. The practice supported staff wellbeing.

People were involved in decisions about their care. The practice provided information people could understand including easy read materials. People knew how to give feedback and were confident the service took it seriously and acted on it. The practice was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The practice worked to reduce health and care inequalities through training and feedback. We saw that the practice had developed and embedded a new approach to improve care and treatment for patients with a learning disability and autism. People were involved in planning their care and understood options around choosing to withdraw or not receive care.

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care, and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas. Since our last assessment we saw that the practice had committed significant time to addressing past concerns, and had put in place procedures and processes to improve overall governance.

Since the last assessment, the practice had made improvements and is no longer in breach of regulations. We saw that the practice had taken action to improve safeguarding processes, the safety management of the premises, staff training and recruitment checks, and overall leadership and governance processes. Medicines optimisation and the provision of care for patients with long-term conditions had shown some improvement, but it was recognised that more work was required by the practice in this area, though this was not considered a continued breach of regulations.

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.