Dalton Terrace Surgery

Updated 4 January 2024

Dalton Terrace Surgery is located in York City at:

Glentworth
Dalton Terrace
York
YO24 4DB

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning, treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the Humber and North Yorkshire Integrated Care Board (ICB) and delivers General Medical Services (GMS) to a patient population of about 9,500. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices. There are 3 GP practices that collectively make up the York City Centre Primary Care Network.

• Dalton Terrace Surgery
• Jorvik Gillygate Practice
• Unity Health

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the ninth lowest decile (9 of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is mainly white.

There is a team of 8 GP partners, 3 salaried GPs and 2 GP registrars. The practice has a team of 3 nurses and a health care assistant and a phlebotomist. There are a range of other staff employed by the PCN who work for the practice. These include first contact physio, care co-ordinators, clinical pharmacists, mental health worker and social prescriber. The GPs are supported at the practice by a team of reception/administration staff. There is a practice manager and assistant practice manager.

The practice is open between 8am to 6pm Monday to Friday and Wednesdays 6.30pm to 9pm. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Vocare is contracted to provide GP cover 6pm to 6.30pm weekdays. Out of Hours 111 cover the period 6.30pm – 8am weekdays and weekends.

As part of the NHS’s Improving Access to Primary Care Services patients can access an appointment outside of normal practice hours on a Friday 6.30pm – 8pm and on a Saturday 9am – 12pm and 1pm – 5pm. These appointments are available to Dalton Terrace Surgery patients as they are part of York City Centre PCN. Appointments are available on a five-week rotation at Dalton Terrace Surgery and at other times at Unity Health and Jorvik Gillygate Practice.

Updated 4 January 2024

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