The Care Quality Commission
  • Doctor
  • GP practice

Moss Street Surgery

Overall: Good read more about inspection ratings

23 Moss Street, Chadsmoor, Cannock, Staffordshire, WS11 6DE (01543) 504477

Provided and run by:
Moss Street Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Moss Street Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Moss Street Surgery, you can give feedback on this service.

During an assessment under our new approach

Moss Street Surgery is a NHS GP practice which provides primary care services to patients in Cannock, Staffordshire. The practice is rated as good overall, with all key questions rated as good. We carried out an announced assessment of one quality statement, equity of access, under the key question Responsive at Moss Street Surgery on the 6 March 2024. We carried out the assessment as part of our work to understand how practices are working to try to meet peoples demands for access and to better understand the experiences of people who use services and providers. We recognise the work that GP practices have been engaged in to continue to provide safe, quality care to the people they serve. We know staff are carrying this out whilst the demand for general practice remains exceptionally high, with more appointments being provided than ever. However, this challenging context, access to general practice remains a concern for people. Our strategy makes a commitment to deliver regulation driven by people’s needs and experiences of care. The assessment of the quality statement equity of access includes looking at what practices are doing innovatively to improve patient access to primary care and sharing this information to drive improvement. We found that the practice had organised services to meet patients’ needs, particularly those who were most likely to have difficulty accessing care. The practice used feedback and other information to monitor and improve access. The practice had taken action to improve access, particularly to how easy it was for patients to contact the practice, but this was not yet reflected consistently in the GP patient survey data or in other sources of patient feedback.

17 November 2022

During a routine inspection

We carried out an announced comprehensive inspection at Moss Street Surgery on 17 November 2022. Clinical searches were undertaken on 22 November 2022. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - good

Following our previous inspection on 20 April 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 Moss Street Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection due to the length of time the practice was previously rated. We assessed all key questions.

How we carried out the inspection

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.
  • Staff feedback questionnaires.

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 had systems in place to keep people safe and safeguarded from abuse.
  • Patients received care and treatment that met their needs.
  • The practice had a system in place for managing significant events however, incidents had not always been identified as an event to improve the quality of patient care.
  • There were effective systems in place to monitor patients prescribed high-risk medicines and monitoring of patients with long-term conditions.
  • Staff had the information they needed to deliver safe care and treatment.
  • The practice had recently obtained partial funding for renovations to the premise to enable improved accessibility for its patient population.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • A new cloud-based system had been installed in August 2020 with improved functions including call recording and additional capacity for calls.
  • Staff enjoyed working at the practice and felt respected, supported, valued and encouraged to do their role.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • Processes for managing some risks were not fully embedded into practice.
  • Patient satisfaction in the National GP Patient Survey 2022 was higher than local and national averages across all indicators in relation to providing caring and responsive services.

Whilst we found no breaches of regulations, the provider should:

  • Review and improve recruitment procedures in accordance with regulations.
  • Review and improve systems to significant events are captured to improve patient care.
  • Review procedures for the oversight of monitoring vaccine fridge temperatures.
  • Develop a programme of targeted quality improvement.
  • Improve the documentation in response to the management of complaints.

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 Hospitals and Interim Chief Inspector of Primary Medical Services

20/04/2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr S R Gibbins and Partners on 20 April 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, effective, caring, responsive and well-led services. It was also good for providing services for older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including those with dementia).

Our key findings were as follows:

  • 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 found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • 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.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group (PPG).

There were areas of practice where the provider should make improvements:

  • Expand the availability of emergency medicines to ensure that they are age appropriate.
  • Introduce a method of recording cleaning activities undertaken to evidence they have taken place.
  • Provide staff with regular appraisals and support personal development plans or record the reasons they cannot be met.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice