Dalton Surgery

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

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.

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

The practice was in breach of legal regulation in relation Regulation 17 – Good governance.

This service scored 36 (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 have a well-defined and embedded vision, values and strategy. During the assessment process, the practice told that they did not have an up-to-date mission statement or strategy. On the day of the on-site inspection, the practice provided a refreshed mission statement and a 5-year business plan. These were not developed in collaboration with staff, people who use the service and external partners. The business plan did not consider the local and wider health and social care community or reference how it would plan services to meet the needs of the practice population groups. There was no indication of how the practice planned to monitor and review the plan.

The management team told us they understood the issues, challenges and priorities relating to the quality and future of services. However, there was no formal and embedded organisational vision and strategy. We found there was a lack of effective governance oversight, and some systems and processes were not sufficiently embedded to ensure safe, effective and well-led care.

Throughout the assessment process, the practice manager was open and transparent and was responsive to all feedback and acted on areas raised as a concern.

Staff told us that managers were visible and approachable and that they felt supported by them. Staff felt they worked well as a team to manage the day-to-day workload.

The practice told us they tried to foster a culture where people felt they could speak up and their voice would be heard. The management team described an ‘open door’ culture. Staff feedback indicated that they would feel confident to raise a concern. There was a Freedom to Speak Up Policy in place. The practice had not nominated a Freedom to Speak Up Guardian within the practice or at primary care network level. However, the policy outlined contact details outside the practice in the wider health community. Not all staff were clear on these arrangements.

The practice supported the safety and well-being of staff. Staff reported a positive culture at the practice. Some staff gave examples of support they had been given by the practice, both personal and professional.

Equality and diversity training formed part of the practice’s mandatory training schedule, but not all staff had completed this.

Although the practice had an overarching governance framework, it was not operating effectively and we found concerns around safeguarding, safe environments, safe and effective staffing, infection prevention and control (IPC), medicines management and the management of patients with long-term conditions.

There was no clear process and understanding of the practice’s legal obligation to notify the Care Quality Commission (CQC) through statutory notifications. The regulations state that a provider must notify CQC when there is a change, event or incident that affects their service or the people who use it.

The practice had a business continuity management plan which had last been reviewed in June 2024. The plan did not include current contact details for suppliers or staff should the plan be activated. There was no system in place to test key elements of the plan and identify lessons learned.

There were nominated leads for key areas whom staff could contact for advice and support. For example, safeguarding of adults and children and IPC. Staff we spoke with were clear about their role, responsibilities, and how they interacted with other staff.

Staff could access policies and procedures and there was a system of reviewing them. However, we found some policies contained out of date guidance and information.

There were monthly formal meetings where discussions about the practice, such as complaints and significant events, were discussed. We saw that meetings were minuted and made available to staff.

There were processes in place to ensure data management and security. The practice was registered as a data controller with the Information Commissioner’s Office (ICO). Staff took patient confidentiality and information security seriously. Staff we spoke with told us they followed the practice’s confidentiality policy when discussing patients’ treatments. This was to ensure that confidential information was kept private, for example, patient information was never on view and computers were locked when not in use. Information governance and general data protection regulation (GDPR) training formed part of the practice’s mandatory training schedule, but the practice could not evidence that all staff had completed these in the last year.

Leaders told us they used a range of methods to gather patient feedback. For example, from the National GP Patient Survey, Friends and Family Test (FFT), complaints and compliments. Staff told us they could provide feedback through meetings and annual appraisal.

The practice had a small Patient Participation Group (PPG), which attempted to convene twice a year. The meetings were attended by a GP Partner and the practice manager and were minuted. We saw that the last meeting had been held in September 2024. The meeting scheduled for February 2025 had been postponed as it coincided with the practice changing clinical systems. The practice had contacted the PPG members in August 2025 by email with some updates and a plan to convene a meeting. We saw evidence that the practice was actively promoting the PPG to encourage patients to join to make it more representative of the practice population.

We saw the practice attended regular primary care network (PCN) meetings.

The practice did not have an embedded culture of improvement and innovation. There was no formal programme of quality improvement, systems and processes to support good governance were not operating effectively and there was no clear vision or strategy to drive a culture of continuous learning.

Staff were supported to undertake further training and acquire new skills. Some staff gave examples of how they were encouraged and supported with professional development.