Dockham 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.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

The service had a learning culture and people could raise concerns. Managers investigated incidents; however, improvements were needed to ensure records kept were in line with the practice’s policies and procedures. People were protected and kept safe. Staff understood and managed risks.

The facilities and equipment met the needs of people, were clean and risks within the practice’s control were mitigated.

Staff had the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care

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 had a culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to identify and embed good practice. However, records related to investigating and taking action on significant events did not clearly show how the process had been followed, as records were incomplete.

The policy for significant events stated the process staff were expected to follow when a significant event was identified, this included effective investigation and recording of findings. Significant event meetings were to be held monthly and also discussed at protected learning time meetings for all staff. We found that significant events were discussed in relevant meetings and findings were recorded, however there was no indication on whether actions identified as a result of a significant event had been completed and monitored.

The practice did not have an active Patient Participation Group. They had a plan to develop this in the New Year.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when people moved between services. Referrals and test results were managed in a timely way.

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 shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

Training records showed that some staff had not received safeguarding training to the recommended level for children and for adults. The practice had identified this following a ‘mock’ inspection and plans were in place to address the shortfalls.

However, at the time of inspection these had not been completed. Reasons why staff had not completed training included long term sickness. The practice had allocated time for staff to complete 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. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. The practice did not have an alternative antibiotic to use in case of an emergency if a person was allergic to penicillin. There was no risk assessment to demonstrate what actions should be taken if this occurred.

The service did not always detected and controlled potential risks in the care environment. However, they made sure equipment and technology supported the delivery of safe care.

During our onsite visit, we observed wedges were being used to prop open fire doors. Leaders told us this was due to ventilation issues within the building. However, the service had not risk assessed the potential fire risks the propping open of fire doors could cause. The service removed the wedges at the time of our onsite visit and confirmed they were in discussion with the landlord about measures to improve ventilation. We were told another service was also located in the same building, and they had data on air quality within the whole of the building, which supported the concerns about ventilation. We requested a copy of the data, but it was not provided.

The practice were due to meet with the landlord and commissioners in November 2025 to discuss the situation further and to look at an appropriate mechanism to enable fire doors to remain open safely. We requested an update once the meeting had taken place, which has not yet been provided.

However, contracts were in place to ensure the premises were otherwise maintained. Other 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 made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. However, improvements were needed to ensure that all required information was contained in staff recruitment files and training as described in the practice’s policy had been completed.

There were a range of clinical and non-clinical roles within the practice The practice had recently introduced GP assistants to the team. They had also employed a pharmacist who was due to start work in the New Year. In the meantime, cover was being provided by a Primary Care Network pharmacist (a group of GP practices who work together to provide care and treatment for people).

Training records showed that the mandatory training on learning disability and autism had not been completed by all staff as required. Staff worked within their agreed areas of competence. We reviewed a sample of recruitment files and found that copies of references were not consistently held within staff records. This was discussed with the practice manager who managed to locate the missing references for 2 of the 3 files which did not have them. Additionally, there was no information to show that relevant health checks had been carried out, prior to a member of staff commencing employment, as detailed in the service’s policy.

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 action plan produced from the most recent audit did not have timescales for completion noted.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was lower than local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.