Dalton Surgery

On this page

• 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 practice leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

At our last assessment, we rated this key question as inadequate due to identified concerns which included significant gaps in management and oversight processes, and the lack of a well-defined vision, values, and strategy for the practice. At this assessment, the rating has changed to good due to improvements made by the practice.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

During the last assessment we saw that the practice had not developed and embedded a well-defined vision and strategy for the service that had been developed in conjunction with staff and other stakeholders. At this assessment we saw that the practice had reviewed and updated their vision and strategy to ensure that it reflected their delivery model, and their approach to the provision of care and treatment, whilst recognising the needs of their population. We heard from staff how they had been involved in this process, and had the opportunity to engage in its development. The practice Patient Participation Group had also been consulted on the practice’s mission statement, vision and strategy. Staff frequently told us that it was their aim to deliver the best care possible to their patients.

The practice had developed a business plan for 2025-2030. This clearly stated the aims of the service and identified key activities which included the delivery of patient-centred care, workforce engagement, quality improvement, and population health.

We found that the practice had inclusive leaders and managers at all levels who clearly understood the context in which they delivered care, treatment and support. We saw that leaders and managers had the skills, knowledge, experience and credibility to lead effectively, and we saw they did so with integrity, openness and honesty.

As part of our assessment, we held interviews with staff from all levels in the organisation, and received questionnaire feedback from a selection of staff we could not directly speak with. From this feedback we heard that leaders, senior managers and line managers were supportive, approachable and inclusive. These views were supported by a staff survey conducted with staff in June 2026. As examples of feedback, we saw that 100% of staff reported that they had confidence in the senior leadership team, and 100% of staff felt that the senior leadership team had communicated a vision for the future which motivated them.

Leaders and managers had developed a strategy and business plan which supported their approach. The practice recognised and effectively planned for the loss and retirement of key staff including an established partner, and we saw that succession planning measures were in place. This included forward recruitment, and the identification of staff for future development.

We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

The practice fostered a positive culture where people felt they could speak up, and their voice would be heard.

Since our last assessment in 2025 the practice had established and embedded freedom to speak up arrangements, and all staff we spoke with knew how to and who to contact if they had a concern that they wished to discuss with them. We saw that an internal freedom to speak up champion had been appointed and that an external guardian was in place and available to staff.

We heard from practice leaders and managers how they dealt with general concerns and issues raised by staff. They told us that they had an open-door policy, and were available for direct contacts from staff when they had concerns, issues, or suggestions to improve the operation of the practice. Staff views confirmed that they worked well with the management team, and felt they could approach leaders and managers.

The practice valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

We saw that there were key policies and procedures in place to promote diversity and equality. These included processes for whistleblowing, and tackling bullying and harassment. The practice had a zero-tolerance approach for dealing with unreasonable, violent and abusive patients.

Staff feedback we received was positive about how the practice supported their wellbeing, and we were given examples of how the practice had supported staff via occupational health referral and reasonable adjustments. The practice actively engaged with their staff. For example, a recent staff survey showed that of 14 responses, all were either extremely satisfied with their employer (13 responses) or somewhat satisfied (1 response).

Since our last assessment we saw that a GP partner had reduced their clinical sessions to enable them to concentrate on the management of healthcare within the practice, seeking to ensure services were safe and effective, and that quality improvement processes were implemented.

When we reviewed training records, we saw that staff had completed mandatory equalities and inclusion training. The practice had a strong focus on staff development and succession planning, and we saw that several staff had received additional training and career development opportunities. As part of the appraisal process training and career development was discussed. Feedback from a recent GP trainee was positive about the support they had been given during their time with the practice.

Staff told us that the practice enhanced social wellbeing for staff with the organisation of events such as quizzes and bingo nights.

The practice had developed and embedded clear responsibilities, roles, and systems of management oversight and good governance. We saw that the practice used information to deliver effective care and to improve services.

Leaders and managers had developed and put an organisational structure in place to ensure the effective management of services. This included the appointment of partners and senior staff to act as leads and champions for key activities such as safeguarding, information governance and for patients with a learning disability or autism.

We saw that meetings were held which supported good governance and management. These included management meetings, clinical meetings, and administration and reception team meetings. We also saw that the staff from the practice regularly engaged with external partners such as their primary care network, and local safeguarding team. These meetings were important for the sharing of service information and updates, and to enable feedback.

Following the last assessment of the service undertaken in 2025 we saw that the practice had dedicated significant time and resources to improve governance and oversight processes. This included adopting an electronic support, compliance, and management platform designed specifically for GP practices, developing and updating policies and procedures including a policy for statutory notifications, and an updated business continuity plan. Oversight measures had also been put in place to monitor training compliance and attainment, and quality improvement measures had been put in place.

The practice understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Leaders and managers collaborated with other practices in their primary care network (PCN) to deliver services such extended access appointments. They also worked closely with PCN staff who supported their patients. This included pharmacy team members.

The practice held multidisciplinary meetings to discuss and improve outcomes for patients with complex needs. This included safeguarding stakeholders, and palliative care colleagues.

We saw that measures were in place to engage with the public and patients. The practice reviewed feedback from patients submitted via the National GP Patient Survey and from NHS Friends and Family Test returns. The practice also undertook its own surveys to assess patient satisfaction with services and changes they had introduced. For example, we saw that the practice had carried out a small patient survey to assess patient views on the move to digital triage-based appointments. The practice also engaged with patients outside the surgery, and we saw that staff had organised park walks for patients and their families as part of the Saturday Park Run Scheme.

The practice had a Patient Participation Group (PPG), but recognised that the group could develop further. A representative from the PPG told us that they felt that the practice respected them and took on board their suggestions and comments.

We saw the practice used a range of media to engage with patients, this included via noticeboards and their website.

The practice focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcomes and quality of life for people. They actively contribute to safe, effective practice and research.

Since the last assessment in 2025 the practice had reviewed its approach to quality improvement and learning. For example, the practice had developed and adopted actions and processes to support quality improvement work. This included undertaking clinical and non-clinical audits into activities such as prescribing and safeguarding. We also saw that formal clinical supervision had been put in place to assess the quality of clinical decision making.

We saw, and heard from staff to corroborate this, how staff were able to give feedback and suggest improvements to services. Staff also told us that they were kept informed of practice developments, and learning from audits and events at meetings and one-to-one contacts. Staff also told us how they were supported to undertake training to enhance their skills, widen their competencies, and to develop professionally.