Dalton Surgery

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• 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 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.

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

This service scored 50 (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 had systems and processes in place to report incidents, near misses and safety events. The system was underpinned by a policy, which included a reporting template. Staff were able to explain the process of how they would report an incident, or who they would seek guidance from to do so. Leaders told us that they promoted a culture of learning and encouraged staff to report incidents openly. The practice had recorded 7 incidents in the last 12 months, which we reviewed. We saw that these had been investigated, and learning shared in meetings.

There was a system to record and investigate complaints. We discussed with the practice manager capturing all verbal complaints and the role and benefit of trend analysis from any verbal complaints.

Although the practice told they fostered a positive culture of safety, all opportunities to contribute to a safe and active learning culture were not embedded. The practice did not have a programme of continuous improvement, including clinical audits, and there was no oversight of incidents and complaints to identify themes and trends.

The practice had systems in place to manage referrals, clinical correspondence, pathology results and medical record summarising but there were gaps in the management of some of these processes.

We observed that there was a system in place to ensure urgent 2-week wait cancer referrals were sent in a timely manner and checks in place to ensure the patient had received an appointment. However, there was no safety-netting system in place to ensure the patient had attended for their appointment and outcome correspondence had been received by the practice. The practice was responsive to this feedback and told us they would add this stage to their process.

We saw there was a system in place to manage incoming clinical correspondence, including changes to patients’ medications, which was undertaken by the pharmacy team. During our remote clinical notes review we found a backlog of outstanding scanned documents, which dated back to February 2025, which had not been coded. The practice told us that they had migrated clinical systems in February and this had been an administrative oversight. After the assessment, the practice told us that these documents had been actioned.

Pathology results were actioned by clinicians and there was a system in place for when staff were absent. The cervical screening sample taker we spoke with demonstrated the system in place for safety-netting cervical screening undertaken at the practice, to ensure that a result was received for each cervical screening sample undertaken.

Clinical records of new patients were mostly received by electronic transfer and those that were received in paper form were summarised in the practice’s clinical record system. The practice had a dedicated summariser, and we saw that 75% of patient records had been summarised. At the time of the assessment, the practice had not completed any formal audits of the summarising process but indicated they would initiate an audit to ensure medical records were summarised in line with their protocol.

The practice had a clinical safeguarding children and adults lead and deputy in place, supported by a nominated administration lead. Staff knew who the leads were, how to escalate safeguarding concerns and were able to give examples of what would constitute a safeguarding concern.

At the time of our assessment, safeguarding policies contained some out-of-date guidance and links. In particular, the policies referenced out-of-date training competency guidance, which impacted on the level of safeguarding children and adults training we found for clinical and non-clinical staff appropriate to their role. Overall, we found gaps in the completion of safeguarding children, adults, preventing radicalisation and chaperoning training. During the assessment, the practice acted upon our feedback and staff were facilitated to commence the appropriate level of training.

The practice had systems in place to follow-up on children with frequent attendance at accident and emergency, and when children had not been taken to secondary care appointments or for childhood immunisations.

The safeguarding lead attended external safeguarding meetings and held regular multi-disciplinary team (MDT) meetings where safeguarding was discussed and documented.

As part of our assessment, we reviewed 2 safeguarding records and found appropriate coding, including household-level linking of records. However, the practice did not maintain formal safeguarding children and adult registers which could be compared and reconciled with external agencies in MDT meetings to ensure the accuracy of safeguarding data and ensure all relevant patients had been correctly identified and flagged.

At our on-site assessment we observed notices displayed in the practice to advise patients that a chaperone service was available, if required. We saw that all staff who acted as a chaperone had received a Disclosure and Barring Service (DBS) check but there were gaps in formal chaperone training undertaken. However, staff we spoke with who undertook chaperoning were able to explain their role and responsibilities whilst chaperoning.

At our on-site visit, we observed that the practice held medical equipment and medicines to respond to medical emergencies, including suspected sepsis. The practice had undertaken a review of the emergency medicines available at the practice based on local context and the services they provided but had not documented a risk assessment to support these decisions.

We reviewed processes around the management of emergency equipment and medicines and saw there were regular checks in place, which were recorded. Records confirmed that all staff had completed basic life support training, which was undertaken annually via face-to-face training and consolidated through on-line training.

Staff told us they were confident in the systems and processes to respond to medical emergencies. Non-clinical staff demonstrated they were aware of ‘red flag’ presenting complaints, for example patients with shortness of breath, and what action to take if they encountered a deteriorating or acutely unwell patient. Sepsis awareness training for clinical and non-clinical staff formed part of the practice’s mandatory training schedule but not all staff had completed this at the time of our assessment.

Staff feedback demonstrated that all staff were aware of the location of the emergency medicines and medical equipment, for example oxygen and the automated external defibrillator (AED). Staff were aware of how to raise the alarm in the event of an emergency and told us they used the panic alarm system within their clinical system.

The practice was located in a 2-storey medical facility, which had been modernised and extended in 2020. Patient services were delivered from the ground floor and consisted of 5 consultation rooms and a treatment room. During the assessment, we found appropriate maintenance contracts in place for gas, portable appliance testing (PAT), medical calibration, fire alarm panel, fire extinguishers, emergency lighting and intruder alarm. However, the Electrical Fixed Installation Condition Report (EICR) was overdue. This had been highlighted in a formal fire risk assessment undertaken in August 2025 as a high priority. After the assessment the practice told us that a maintenance review had been scheduled for November 2025.

The practice had undertaken premises risk assessments, which included health and safety, Control of Substances Hazardous to Health (COSHH) and Legionella. Water temperature testing was undertaken monthly. A fire risk assessment had been undertaken by an external contractor in August 2025. At the time of the assessment the practice was addressing the time-lined action plan.

Weekly fire alarm testing was undertaken, and a fire evacuation drill had been undertaken in October 2025, both of which had been recorded. We saw from records that an evacuation drill was undertaken at 6-monthly intervals. There was a nominated and trained fire marshal in place. We saw from the fire risk assessment that face-to-face fire awareness training, and fire marshal training for additional staff, had been scheduled for December 2025.

As part of our on-site assessment, we reviewed 3 clinical and 1 non-clinical recruitment file of staff who had commenced since our previous inspection. Two of the clinicians were locum staff who undertook regular sessions at the practice. We found all files reviewed included evidence of a Disclosure and Barring Service (DBS) check, a signed contract and a professional registration check, where appropriate. However, we found some gaps in documentation which included appropriate reference checks for 3 staff members and photo-ID for 1 staff member.

There was a system in place for staff induction, and we saw evidence of this in the recruitment files we reviewed. However, the induction check list was generic and was not tailored to specific staff roles.

The practice had identified mandatory training for clinical and non-clinical staff. However, we found some training was not at a level in line with guidance based on staff role and there were gaps in up-to-date training, which included safeguarding children, safeguarding adults, preventing radicalisation, mental capacity act, infection prevention and control, fire awareness, sepsis and equality and diversity. There was no system in place to record or have oversight of role-specific training and we found gaps in the training records maintained for a locum practice nurse.

There was a process in place to ensure staff had regular appraisals. Clinical staff we spoke with told us they felt fully supported clinically. However, there was no system in place to formally audit the consultations and prescribing of independent prescribers.

The practice supported staff upskilling and development where possible and we saw that the practice had supported a receptionist to train as a healthcare assistant and were further supporting them to become a nursing associate.

The practice had a nominated infection prevention and control (IPC) lead and policies in place. We spoke with the nominated lead who told us they had dedicated time to undertake their responsibilities and had completed additional IPC training to support them in this extended role. Annual IPC training, at a level appropriate to staff role, formed part of the mandatory training schedule. However, we found not all staff had completed this training.

The practice had undertaken an IPC audit in November 2024 which had attained 95% compliance. We saw that remedial actions identified had been completed.

There was a system in place to capture the immunisation status of staff at the point of recruitment, but this was not in line with current guidance, and we found gaps in the staff records we reviewed.

The arrangements for managing waste and clinical specimens kept people safe. We found posters around the practice including the management of sharps injuries, handwashing and clinical waste to support good practice. Appropriate personal protective equipment and bodily fluid spillage kits were available to staff.

Cleaning was undertaken by contract cleaners, who had access to appropriate colour-coded equipment and cleaning materials in a dedicated locked area. On the day of the on-site inspection, we observed the premises to be clean, tidy and clutter-free.

As part of our assessment, a CQC GP specialist advisor (SpA) conducted a series of remote clinical searches of patient records to assess the practice’s procedures around prescribing and medicines management. These searches included patients prescribed disease-modifying antirheumatic drugs (DMARDs), medicines which required patient monitoring, medicines subject to a patient safety alert, medicines usage and medicines reviews. Although there were systems and in place to recall and manage patients in line with guidance, we found some gaps in these processes, and we highlighted some patients for further review by the practice.

There were 30 patients prescribed the DMARD Methotrexate, of which 3 did not appear to have had monitoring in the last 6 months. We reviewed the patient records and found blood test monitoring had been undertaken by secondary care and the results documented in correspondence. The practice told us they reviewed these results prior to prescribing. However, there was no documented evidence in the practice’s clinical system that the clinician had checked that monitoring was up to date before issuing a prescription. For 2 patients reviewed, there was no shared care agreements saved in the practice’s clinical system. Shared care agreements should be in place and easily accessible. A specialist should advise which medicines to prescribe, what monitoring will need to take place in primary care, how often medicines should be reviewed, and what actions should be taken in the event of difficulties. After the assessment the practice gave feedback that local secondary care do not always provide these documents. None of the patients we reviewed had the day of the week on which this medicine should be taken in line with the September 2020 Medicines and Healthcare products Regulatory Agency (MHRA) alert. After the assessment the practice told us they would have further discussions around the management of patients prescribed DMARDs.

There were 187 patients prescribed a direct oral anticoagulant (DOAC), of which searches indicated 32 had never had a creatinine clearance level calculated. We reviewed 4 records in detail and found no creatinine clearance had been calculated for any of the patients. The dose adjustment for DOACs is based on the calculation of creatinine clearance (a marker of how quickly the body excretes the medicine through the kidneys), which is calculated using readings from renal function blood tests, patients age, sex, height and weight. Under-dosing the medicine could leave the patient at higher risk of a blood clots and/or stroke and an overdose could increase the risk of severe bleeding. We asked the practice to review an individual patient regarding medicine dosage. After the assessment, the practice confirmed they had reviewed the patient, and the medicines dosage had been amended. In addition, the practice confirmed that the pharmacy team would review this cohort of patients.

We reviewed patients prescribed the concomitant use of aldosterone antagonists (spironolactone or eplerenone) with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB) and searches indicated 15 had not received the required monitoring in the last 6 months. We reviewed 5 records and all 5 were overdue monitoring. For 3 of the patients, the practice had identified patients were overdue monitoring and had taken steps to address this. For 2 of the patients, the practice had recognised that blood tests were overdue but no recent recall had been undertaken. The concomitant use of these medicines increases the risk of severe hyperkalaemia (raised potassium levels), particularly in patients with marked renal impairment. Raised potassium levels may cause heart arrythmias and muscle weakness and can be fatal. After the assessment, the practice told us the pharmacy team had already reviewed this cohort of patients and recalled for monitoring.

There had been 169 medication reviews in the last 3 months. Medication reviews should ensure the medicines a patient is taking are still appropriate, that monitoring is up to date, relevant safety information/advice addressed, and medicines should be aligned. It should be clear from the notes whether a patient had been involved in the review. We reviewed 5 records and found gaps in the quality of medication reviews.

The management of some patients on benzodiazepines and Z drugs was not in line with guidance. Benzodiazepines are medicines that may be used as a short-term treatment for severe anxiety and Z drugs are medicines that may be used as a short-term treatment of severe insomnia. There were 57 patients identified as having been prescribed over 10 prescriptions for benzodiazepines or Z drugs, of which we reviewed 4 patients. There was no documented evidence in the clinical notes that there had been an attempt to wean any of the patients off the medication and only two had documented evidence that they had been informed of the risk of addiction. After the assessment the practice told us they would discuss the use of a template with all clinicians to ensure discussions with patients were appropriately recorded and coded.

At our on-site visit, we found vaccines were appropriately stored, monitored and transported in line with guidance to ensure they remained safe and effective. Medical gases, such as oxygen, were stored safely with appropriate warning signage.

Staff had the appropriate authorisations to administer medicines, including Patient Group Directions and Patient Specific Directions.

Blank prescription stationery was securely stored, and their use was monitored in line with national guidance. The practice did not have a system to remove the stationery from printer trays when not in use or overnight. At the on-site inspection the practice told us they would initiate a system immediately.

Data showed that the practice had systems in place to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. We saw that prescribing outcomes were broadly in line with average outcomes.