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

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

Leaders had and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

We found breaches of regulation in relation to good governance. Although there were identified staff for lead roles, there was no clear overarching governance system to show how the service provision would be monitored; and how the provider could assure themselves that systems and processes were working effectively. We have asked the provider for an action plan in response to the concerns found at this assessment.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a vision and strategy in place. Some staff said that they had not contributed to the development of the service vision and strategy, however they were aware of its contents. Some staff told us that there were meeting in place, but they were not always able to attend.

Staff who had recently been employed commented that colleagues had been welcoming, and they noticed that staff were focussed on providing good care and treatment.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders in the practice was approachable and responded to any concerns raised. Leaders had started to work with other practices in the primary care network and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where the staff felt they could speak up and their voice would be heard.

Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

The Freedom to Speak Up Policy detailed other agencies staff could contact if they were not confident to speak up to the relevant people in the organisation. Staff confirmed they were aware of these agencies.

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

Policies and procedures to promote diversity and equality were in place. We saw senior leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support disabled staff were in place.

Improvements were needed to ensure that there were effective systems of accountability and good governance; to manage and deliver good quality, sustainable care, treatment and support.

The service had been under a new partnership since March 2025 and had undertaken a review of service provision, which was ongoing. An action plan showed dates for completion, but work had not been completed to ensure these target dates would be met.

Although there were identified staff for lead roles, there was no clear overarching governance system to show how the service provision would be monitored; and how the providers could assure themselves that systems and processes were working effectively.

Improvements were needed to ensure that the complaints system was effective and all concerns were appropriately investigated and responded to; and learning shared with relevant staff.

The provider was aware of issues with use of wedges to prop open fire doors and was working with the landlord to rectify this. However, no risk assessment relating to the fire safety of the service had been conducted in relation to the use of these wedges.

Policies and procedures had been reviewed, but some policies referred to outdated information. For example, the policy on duty of candour referenced CQC’s key lines of enquiry, which has been replaced by the Single Assessment Framework since 2023.

Regular staff meetings were in place since the new partners had taken over the running of the service, which had been welcomed by staff. However, clinical meetings were for GPs or nurses and there were no joint meetings for all clinicians to discuss care and treatment, which some staff said they would like to have.

Information about risk, performance and outcomes was collated, but the provider could not assure themselves that this information was used consistently to drive improvement. Action plans resulting from a ‘mock’ inspection carried out in June 2025, had a timescale set by the service for all actions to be completed by 31 October 2025. However, not all areas were on track to be completed by this time. There was no detailed information on the action plan to show progress and whether timescales needed to be amended with reasons given to indicate why there was a delay.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission.

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

The practice had a quality improvement plan in place to help drive improvements in services which was developed in response to a ‘mock’ inspection.