Dalton Surgery

On this page

• 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.

At our last assessment, we rated this key question as requires improvement due to identified concerns which included gaps in systems and processes around safeguarding, safe environments, safe and effective staffing, infection prevention and control, and medicines management. At this assessment, the rating has changed to good overall, although there are some areas where the practice still needed to make improvement.

This service scored 69 (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 identify, record and investigate incidents, near misses, complaints and patient safety events. Lessons were learnt to continually identify and embed good practice.

Staff we spoke with were able to clearly explain to us how they would report an adverse incident or learning event. Staff furthermore told us that they felt able to raise concerns. Over the previous 12 months the practice had recorded 5 significant events. We saw that these had been investigated, and improvements put in place to prevent recurrence. For example, following a needlestick injury the practice took action to reinforce training and competency checks for staff undertaking clinical procedures. Significant events were also examined to identify any emerging themes. We saw from a review of team minutes that events and learning were actively shared with staff.

Complaint processes were embedded within the practice, and we saw that these had been effectively recorded, investigated, and appropriate responses made in line with current guidance.

The practice had reviewed their approach to quality improvement, and we saw evidence which showed how clinical audits, incidents, events and complaints resulted in changes that improved care for others.

A representative from the Patient Participation Group (PPG) told us the practice took concerns and suggestions seriously and proactively made improvements to the service.

The practice had some systems in place to manage referrals, clinical correspondence, pathology results, and medical summarising. However, we saw that there were some backlogs regarding correspondence and summarising which the practice recognised, but still needed to effectively tackle.

We saw that referral processes such as urgent suspected cancer referrals were managed and that monitoring was in place to ensure that the patient had received an appointment. We noted that there was a correspondence backlog of over 800 documents which were awaiting coding and filing. The practice acknowledged this backlog, but in mitigation told us that this correspondence had been assessed and prioritised with urgent correspondence being dealt with on receipt. Since the assessment visit, we have been informed by the practice that this backlog is being dealt with.

Pathology results were dealt with by clinicians, and the practice had processes in place to arrange for these to be dealt with by other staff should the original clinician be absent for an extended period. Our clinical searches showed the timely handling of results.

We noted that a summarising backlog of incoming medical records had also developed within the practice with 872 requiring processing. The practice was aware of this issue, and told us that most of these records were historic. Performance regarding newly received records from January to June 2026 showed that of 148 new records received, 112 had been summarised. When we discussed this with the practice, they told us that they had devised a plan to tackle this backlog through dedicating staff time to this task with a target of clearing the backlog within 12 to 18 months. Summarising performance was being actively monitored by the practice.

Patient discharge support processes were in place with summaries of discharges being reviewed and necessary changes to, coding, medications and care packages being made. Shared care arrangements were in place for patients with complex and ongoing needs.

The practice worked with patients and health and social care partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patient’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

During interviews we found that staff had a good understanding of safeguarding. They gave clear examples of when they would raise concerns, and knew the appropriate routes to take to inform appointed internal safeguarding leads and external partners. Since the last assessment in 2025 the practice had updated their policy for safeguarding children and adults.

The practice utilised their clinical system to support their safeguarding approach. For example, they recorded if a child was not brought in for an appointment, and used this to track any developing concerns. We noted that in some child safeguarding records that not all cohabiting adults had been coded with a necessary alert. Since our assessment visit, we have been informed by the practice that this coding has been completed.

In June 2026 the practice had undertaken child and adult safeguarding audits. Overall, these audits showed that the practice had good compliance levels.

Safeguarding concerns were discussed at both internal practice clinical meetings, and the safeguarding lead also met regularly with external safeguarding partners and stakeholders. Safeguarding was also a standing agenda item for internal practice clinical meetings.

Checks on training records showed that staff had been trained in safeguarding to levels appropriate to their roles. Other training in the prevention of radicalisation and chaperoning had also been completed when required.

The practice worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

During our visit to the practice, we saw that emergency equipment and medicines were available to respond effectively to medical emergencies and incidents. Equipment was well maintained and subject to regular checks to ensure it remained suitable for use. Staff we spoke with knew the location of the emergency equipment and medicines, and were aware how to respond to incidents. Risk assessments had been undertaken for decisions made regarding the stocking of emergency medicines. Record checks showed that staff had received basic life support training Staff could recognise a deteriorating patient and knew of action to take. Sepsis awareness training had also been undertaken by staff and the practice had procedures and processes in place to assess patients with symptoms of sepsis. In addition, the practice undertook audits to ensure important presenting conditions such as shortness of breath were being acted upon appropriately.

Patients were advised on risks related to their condition and actions to take if their condition deteriorated. During our onsite visit we heard safety netting information being relayed to patients. The practice website carried information for patients regarding out of hours care providers and methods of contact.

The practice worked to identify and control potential risks within the care environment. Equipment and facilities supported the delivery of care and kept both patients and staff safe. The practice had put policies and processes in place which gave assurance that health, safety, and wellbeing requirements were met. For example, we saw that a fire risk assessment had been undertaken in 2025. Other checks undertaken included checks on the condition of the fixed electrical installation, this had been overdue at the time of the last assessment of the service in 2025.

We saw evidence that regular testing, maintenance, servicing, and calibration of clinical equipment had taken place. We found that fire safety risks were being managed, and that regular fire alarm checks and fire evacuation drills had been carried out.

To support the maintenance of a safe environment we saw that staff had received training in health and safety which included fire safety training. Staff with additional roles such as fire marshals had also received appropriate training

There was a business continuity plan in place which was monitored, reviewed, and carried up to date contact details.

The practice made sure there were always enough qualified, skilled, and experienced staff, who received thorough support, supervision, and development opportunities. They worked together to provide safe care that met individual needs.

We saw that induction and support procedures were in place for new staff including locum staff. Induction included an introduction to the practice, mandatory and role specific training, and ongoing mentoring, supervision and appraisal.

We saw that managers had a good understanding of staff capacity and patient demand. Rotas were in place to support the scheduling of staff. When we spoke with staff, they told us that they felt that there were appropriate numbers of staff on duty. During holiday periods or during other staff absences the practice told us that they offered additional hours to staff or used locum and agency cover.

During our onsite visit we saw that recruitment had been undertaken appropriately, and an assessment of training records showed that staff had undertaken mandatory and role specific training.

Checks on personnel records showed that staff had regular appraisals. Staff also had access to one-to-ones, and to mentorship and other support when required. This was confirmed by staff that we spoke with or received questionnaires from during the assessment. The practice operated with a duty doctor available to deal with triage and emerging issues, which included the support and advice for other staff.

We saw that clinical supervision processes were in place for clinicians, including non-medical prescribers, which included sessional debriefings, and assessments and audits of key activities such as consultations and prescribing. The approach to clinical supervision was supported by a clinical supervision policy. We received feedback from a clinician who had been supported as a GP trainee at the practice. They told us how well the practice had treated them, and actively supported their learning and developing clinical practice.

The practice had systems and processes in place to manage infection prevention and control (IPC). This included the appointment of a trained staff member to act as the practice’s IPC lead, the development of an IPC policy which was kept regularly updated, and the undertaking of regular IPC audits which assessed the levels of operational compliance against standards. Audits included full IPC audits and regular hand hygiene audits. The overall management of IPC processes and controls under the IPC lead was very organised and thorough.

Since the last assessment we saw improved levels of staff IPC training compliance during their induction, and annually thereafter. The practice had processes in place which gave assurance that staff had received necessary vaccination and immunisations to allow them to safely deliver services.

Our onsite visit to the practice showed that it was clean and maintained in a good overall structural condition. We found that clinical waste was being handled and stored safely, and that a clinical waste disposal contract was in place.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

As part of our assessment, a CQC GP specialist advisor (SpA) undertook a series of remote clinical searches to patient records. This was to assess the practice’s processes and procedures in relation to prescribing and the management of medicines. Remote searches included patients who were prescribed a range of medicines which included disease modifying antirheumatic drugs (DMARDS), medicines which required patient monitoring, medicines which had been subject to safety alerts, medicines usage and medicines reviews.

We found that all patients in receipt of DMARDS had been monitored and managed in line with guidance and best practice.

In respect of the monitoring of patients in receipt of high-risk drugs we found that overall drug monitoring recall processes were in place and patients had undertaken necessary testing. For example, of 205 patients in receipt of a direct oral anticoagulant (DOAC) only 3 patients had not had a creatinine clearance calculation undertaken (necessary for correct dose checking). A relatively small number of patients were overdue for blood monitoring, but of those we reviewed these were only slightly overdue.

Overall, we found that medicines alerts had been appropriately actioned and managed. For example, 41 out of 43 patients with the concomitant use of aldosterone antagonists with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB) had received the necessary monitoring outline in the alert. This had improved from our finding during our last assessment when we identified 15 patients who had not been monitored. However, we did find that women of childbearing age in receipt of teratogenic medicines (a medicine which is used to treat a condition, but which carried with it a risk of causing foetal abnormalities) had not been effectively managed and out of 5 records checked 4 did not have the correct documentation in place. We discussed this with the practice who quickly developed an action plan which included reviews of all patients (some of these were complex patients with additional needs), with the discussion of risks and necessary contraception, and enhanced checks to monitor activity and correct documentation.

For medicines usage we examined patients in receipt of benzodiazepines and Z drugs (used to treat anxiety and insomnia, but can with extended use lead to dependency and addiction). Of 54 patients who had been prescribed over 10 prescriptions we found evidence that suggested 2 patients were potentially over ordering or overusing the medicine, this had not been raised at a past medication review. When we discussed this with the practice, they told us they were aware of some early ordering by patients, and that engagement with such patients had proven difficult. Overall, 4 patients had received a medication review in the past 12 months without the mention of the use of benzodiazepines and Z drugs. We did though see that the practice had introduced a new management template, and that 4 of these patients had received a recent GP consultation when usage and attempts to wean the patient off the medicine was discussed. In 1 of these instances the patient agreed to a reduction. The practice also raised with us that on occasion patients were encouraged by the local pharmacy to request this medication in advance to ensure its availability. They also outlined other measures which they intended to implement which included continuing to review patients using the new template and to initiate reduction conversations, no new patients would be initiated on these medications long-term unless for exceptional clinical circumstances, and newly registered patients on these medications will be invited to a face-to-face review with a senior GP to discuss usage and reduction.

We saw the practice had undertaken 685 medicines reviews in the past 3 months. Results regarding the quality of these were mixed, with 1 being very detailed, 2 carrying little detail with no conversation details with the patient being recorded and no medicine mentioned by name. Finally, we found evidence of inappropriate coding being applied to some reviews. In response to our findings the practice told us that they would use a standardised template for completion during medicines reviews, and remind staff to add more written detail of the review.

We also noted during our assessment that the practice had higher than average prescribing rates for Pregabalin and Gabapentin (used in the management of several disabling long-term conditions, including epilepsy and neuropathic pain), with a rate over twice that of the national average. The practice told us that they would investigate this further.

Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Clear clinical supervision and support processes were in place to assess consultations and prescribing decisions. This was supported by clinical audit processes. Medicines management was discussed at clinical meetings and at individual appraisal and performance meetings.

During our onsite visit we saw that vaccines were appropriately stored and used, and medical gases such as oxygen, were stored safely and with appropriate signage. Checks on Patient Specific Directions and Patient Group Directions showed that staff, when required, had been appropriately authorised to administer medicines.