Moss Street Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

People were involved in assessments of their needs. Our clinical searches found monitoring of patients with long term conditions was largely satisfactory. However, some exceptions were identified, such as patients with the potential for a missed diabetes diagnosis and their electronic coding for diabetes. The service had met all the 90% targets for childhood immunisations for the period 01/04/2024-31/03/2025 and one met the 95% World Health Organisation (WHO) target. Cervical screening uptake NHS England data 30/06/2024 showed that both age ranges were below the 80% target. However, the unverified data evidence for 2025/2026, shown to the Care Quality Commission, demonstrated these were now all above the 80% target including the numbers of patients eligible and those that attended. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people took decisions in people’s best interests where they did not have capacity.

This service scored 71 (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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeingand communication needs with them. However, systems for identifying people with previously undiagnosed conditions were not consistently effective.

Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. Reception staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff checked people’s health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing.

Our clinical searches found the monitoring of patients’ long-term conditions to be satisfactory.

The provider had systems in place to identify people with previously undiagnosed conditions. However, our clinical searches identified 17 patients with potential for a missed diabetes diagnosis. Five were excluded due to duplicate results. Of the remaining 12, 5 records were reviewed: 3 patients had diabetes but were not electronically coded; 1 had a recent diagnosis and required a clinic follow-up and eye screening; 2 had been notified but not responded. Findings from clinical searches were shared with the provider to support further action and strengthen monitoring oversight processes.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The service mostly planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was provided in line with current guidance.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. Staff were positive about how the different staff groups now worked together within the practice and told us there was now a supportive culture across the whole team.

The service supported people to manage their health and wellbeing to maximise their independence, choiceand control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. A named GP led on palliative care within the practice with administration support as required. Nominated reception staff members lead on areas such as a carer champion. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves. Uptake of cervical screening was below target.

Data (01/04/2024–31/03/2025) showed childhood immunisation uptake met the 90% target across all areas, with one indicator achieving just above the World Health Organisation (WHO) 95% standard.

Cervical screening uptake (NHS England data, 30/06/2024) was 74.8% for women aged 25 to 49 and 75% for those aged 50 to 64, below the 80% target. Systems were in place to recall non-attenders, with opportunistic screening offered and prompts on patient records. Cancer screening was also promoted via the waiting room posters and website. Screening uptake rates were regularly discussed in clinical and team meetings, with actions and initiatives identified to improve attendance.

From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. We sampled 4 records as identified in our clinical searches with a Do not attempt cardiopulmonary resuscitation (DNACPR) decisions in place. Capacity and consent were clearly recorded in most of the records. There were minor areas for future discussion at appropriate times with a patient identified whose preference discussion took place in secondary care. We found DNACPR decisions were appropriate and were made in line with relevant legislation. Audits of these records had been regularly completed in the past.