Dalton Surgery

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

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.

At our last assessment, we rated this key question as good. At this assessment, the rating has changed and is now rated as requires improvement.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice did not always make sure patients were at the centre of their care and treatment choices. Our review of people’s records showed gaps in systems and processes to recall patients in line with guidance. For example, there were delays in blood testing monitoring, medication reviews and potential diagnosis which impacted on person-centred care and treatment.

Staff recognised the diverse health and care needs of the practice population. The practice held registers of different patient groups, including those with a learning disability and carers. The practice registered patients with no fixed abode by using the practice as their address.

The practice was aligned to 2 care homes and provided regular face-to-face ward rounds, coordinated between the practice and the homes. We sought feedback from the homes and received positive feedback about their relationship with the practice. One of the homes supported people with a learning disability and they told us the practice was very flexible and offered reasonable adjustments when booking annual health checks.

Staff told us that the practice provided information in formats that were tailored to individual patient needs. For example, patients could request information in more accessible ways, such as in large print.

Reasonable adjustments were made at the practice to support communication and interpreter services, including British Sign Language (BSL), were available for those who did not speak English as a first language. The patient check-in system was aligned to several languages in line with the patient demographic. There was an induction hearing loop.

The practice website had the functionality to translate to other languages, it included up-to-date information about opening times, out of hours information, patient registration, clinics and services, health information and support.

Staff told us the different ways that patients could share feedback and ideas and raise complaints. This included the NHS Friends and Family Test (FFT), the complaints process and through compliments. Staff we spoke with understood the complaints process and how to assist patients with any complaints or concerns they may have.

There was a system in place to record and investigate written complaints. We reviewed complaint records and saw complaints were actioned in an appropriate and timely manner, discussed in meetings, and learning shared. However, complaint responses we reviewed did not include appropriate signposting to the Parliamentary and Health Service Ombudsman (PHSO). The practice did not have a consistent system to capture and record all verbal complaints to facilitate trend analysis.

Patient feedback from the recent National GP Patient Survey in relation to access was broadly in line with national averages. We found 76.2% of patients responded positively to the overall experience of contacting the practice (national average 69.6%), 64.8% responded positively to how easy it was to contact the practice by phone (national average 52.9%), 51% responded positively to how easy it was to contact the practice using their website (national average 51%) and 55% responded positively to how easy it was to contact the practice using the NHS App (national average 49%).

The practice made sure that patients could access the care, support and treatment they needed when they needed it. Appointment types included telephone and face-to-face. Appointments could be booked on the day or in advance, by telephone, online, or at the practice. The practice provided enhanced access on Tuesday from 6.30pm to 8pm. The practice undertook home visits, and the nursing team delivered the annual influenza and coronavirus vaccinations to their housebound patients.

Patients could be referred to additional services in the locality including improving access to psychological therapies (IAPT), first contact practitioners for physiotherapy, health wellbeing coaches and social prescribing services. The practice utilised the Kirklees Urgent Community Response (UCR) service for those patients falling within its criteria.

The practice premises were accessible, which included a ramp, an automatic door to the entrance to the practice and an accessible parking space in the car park. Consultation and treatment rooms were on the ground floor.

During our assessment, we looked at how the practice adapted and provided care to people whose circumstances may make them vulnerable, which included people with a learning disability. In particular, we looked at how the service ensured that care, support and treatment met the needs and preferences of these individuals.

At the time of our assessment, the practice was in the process of reviewing and refining their systems and processes around the care of people with a learning disability. We saw they were in liaison with Kirklees Adult Learning Disability Health Service who had shared information and literature in easy read format with simple text and images to support the health check process, which included the VIP hospital passport. We saw that the practice had reviewed their learning disability register to ensure that those on the register had been included appropriately and had increased the duration of their face-to-face health checks.

We saw that the practice had developed a learning disability information board in the waiting room and had recently nominated 3 learning disability and autism champions who were a GP, a practice nurse and an administrator. At the time of the assessment their roles and responsibilities were being defined and established so it was not possible for the practice to demonstrate how these roles would work.

At the time of our assessment, all practice staff were in the process of completing learning disability training. We saw that 2 face-to-face and interactive training sessions, co-produced and co-delivered by people with a learning disability and autistic people, had been scheduled in October 2025. Additional awareness training had also been scheduled with the Kirklees Adult Learning Disability Health Service team at the October practice protected training session.

As part of our assessment, we reviewed the practice’s management and oversight of advance care planning systems, end of life care and do not attempt cardiopulmonary resuscitation (DNACPR) decisions. The practice kept a palliative care register and patients at end of life were reviewed in monthly multi-disciplinary team meetings.

Clinicians told us that when needed they supported patients and involved their families, carers and other professionals to make decisions in the person’s best interests, including decisions about (DNACPR) and the use of Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) care plans.

We reviewed 4 patient records and found in 2 records a ReSPECT care plan had been used and recorded by the practice with the patients’ wishes regarding care and resuscitation and these were stored in the clinical records. In the other 2 records, we found that DNACPR decisions had been made in other health settings, and coded in the clinical records, but no documentation was available in the notes. The practice did not have a system in place to review and follow-up on any decisions made in secondary care or the community setting to ensure appropriate documentation was available.