Northdown and Dashwood 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

Staff knew how to raise concerns and had confidence in the management team to address risks. They understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Staff managed medicines well and involved people in planning any changes.

However, significant events were not always managed effectively to ensure learning was identified and shared to prevent recurrence. Not all clinical staff received formal supervision to ensure high-quality care was maintained

This service scored 63 (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 did not always have a proactive culture of safety which supported the timely review of incidents and embedding of changes following an incident.

The service was unable to evidence that learning identified from incidents were consistent and embedded in practice. For example, following an incident in October 2025 where a 10 day delay had occurred for a 2 week wait referral due to an administrative task being missed, the service identified that queries relating to these referrals should be managed in person rather than using the online clinical system. However, on reviewing the service’s protocol, there was no evidence to demonstrate that it had been updated to include this new process or that staff had been made aware of the new communication requirements. Learning relating to this incident remained unclear as meeting minutes from November 2025 where this incident was discussed did not reflect the learning previously identified. Instead, it identified a different process for sending clinical tasks. No evidence was provided to demonstrate protocols had been updated in response.

The service did not always share learning in a timely way to ensure improvements to prevent recurrence were embedded in practice. Incidents which had occurred from June to October 2025 were not discussed as part of the wider practice team until November 2025. The service told us this was due to operational pressure experienced with the introduction of their new digital triage system, however they told us all immediate risks had been mitigated at the time the incidents occurred.

However, representatives from the Patient Participation Group (PPG) felt the service took concerns seriously. Managers encouraged staff to raise concerns when things went wrong, and staff told us they knew who and how to report issues.

Following the merger between Dashwood Medical Centre and Northdown Surgery in September 2025 delays had occurred in the processing of patient information. During inspection we identified 1,424 documents dating back to October 2025 requiring review. The service was aware of this and had a system in place to prioritise high risk documents and address the backlog. They had also identified actions to prevent recurrence.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service identified, shared concerns quickly and appropriately to keep people safe. For example, the practice was recognised as a safe place by some people where they may seek support.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures.

The practice maintained a list of vulnerable persons. However, some records for children in care did not include details of who had parental responsibility for them and not all records associated with safeguarding concerns had been appropriately identified. For example, we found a family member had not been flagged as connected with someone under a protection order. (Parental responsibility refers to the legal rights and duties a parent has regarding their child's upbringing, including decisions about their education, healthcare, and where they live. Following inspection, the practice contacted people to seek clarity on this.)

The service 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.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. People were advised on risks related to their condition and actions to take if their condition deteriorated.

The service identified, mitigated and removed potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. For example, fire risk assessments had been completed in March 2025 and actions identified and resolved. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

The service told us that staff were able to access support through their ‘Roundhouse’ model which included an open-door policy enabling staff to access clinical advice and support throughout the day. They conducted annual appraisals and prescribing audits for non-medical prescribers. However, the service were unable to demonstrate how they ensured clinical practice for GPs remained safe and effective as they did not have a process of formal supervision.

Staff told us colleagues were accessible if they requested support or guidance. We found clinical and administrative staff had positive relationships with their colleagues, receiving peer support and supervision.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff felt confident managing the storage and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines.

They had systems in place to record and respond to Medicines and Healthcare products Regulatory Agency alerts. For example, men taking a medicine used to treat epilepsy and bipolar disorder had been informed by letters sent by text of the potential risks of their medication associated with neurodevelopmental disorders in the unborn child.

We found medicine reviews were well documented and supported people to help them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

Waste medicines were recorded and disposed of appropriately including medicines returned by people.

Staff stored medical gases, such as oxygen, safely with appropriate signage displayed.

Clinical audits of prescribing had been conducted and focused on improving care and treatment for people.

However, the service did not store all recommended emergency medicines at the Dashwood site. We identified they did not hold a medicine used for the treatment of epilepsy. The service had risk assessed the potential impact of this, however they had not ensured that contingency arrangements were embedded to ensure they could access necessary medicines if required. We raised this with the service during inspection and they had ordered the missing medicine by the end of the day.

Staff had appropriate authorisation to administer medicines. However, we found one patient group direction (PGD) had not been authorised in line with guidance. The service took immediate action to rectify this during inspection.