The Care Quality Commission
  • Doctor
  • GP practice

Dalton Terrace Surgery

Overall: Requires improvement read more about inspection ratings

Glentworth, Dalton Terrace, York, North Yorkshire, YO24 4DB (01904) 658542

Provided and run by:
Dalton Terrace Surgery

All Inspections

10 November 2023

During a routine inspection

We carried out an announced comprehensive at Dalton Terrace Surgery from 6th to 10th November 2023. Overall, the practice is rated as requires improvement.

Safe - inadequate

Effective - requires improvement

Caring - good

Responsive - good

Well-led - requires improvement

During the inspection process, the practice highlighted efforts they were making in response to the findings from our clinical searches to improve outcomes and treatment for their population. These actions and plans had only recently been implemented so there was no verified evidence to show improvement in processes and impact on patients. As such, the ratings for this inspection were not impacted.

Following our previous inspection in 2015, the practice was rated good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dalton Terrace Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. We reviewed all five key questions.

  • Safe
  • Effective
  • Caring
  • Responsive
  • Well led

How we carried out the inspection/review

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A site visit.
  • Gathering feedback from other organisations.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We found that:

  • The practice did not always provide care in a way that kept patients safe and protected from avoidable harm. There were inadequate systems to assess, monitor and manage risks to patient safety. Systems were not embedded to keep people safe and safeguarded from abuse.
  • Patients did not always receive effective care and treatment that met their needs. The practice did not always routinely review the effectiveness and appropriateness of the care it provided. The practice was not able to consistently demonstrate that staff had the skills, knowledge, and experience to carry out their roles.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way.
  • The practice had a culture which aimed to deliver high quality sustainable care.
  • The overall governance arrangements within the practice were ineffective, resulting in the concerns identified during the CQC inspection.

We found 2 breaches of regulation. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

3 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dalton Terrace Surgery on 3 November 2015. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and any decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • There were appointments available on the day of inspection. We were told there was always continuity of care, and urgent appointments were available the same day, every day.
  • The practice had good facilities however there were some building refurbishments required identified on the day. The practice was equipped to treat patients and meet their needs.
  • There was a leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.

We saw one area of outstanding practice:

  • Each GP had a personal patient list. Patients were known by their GP, and their care co-ordinated in an efficient and effective way to ensure continuity of care. When GPs were away a comprehensive handover was provided to the duty doctor.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice