Moss Street Surgery

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

People were involved in decisions about their care. The service provided information people could understand, which included documents in braille and easy read. People knew how to give feedback and were confident the service took it seriously and acted on it. The service had policies and training for staff and worked to eliminate discrimination. A telephone audit undertaken in December 2025 identified an average monthly demand of 3,758 calls, with peak pressure occurring during morning access periods. Key issues included high call abandonment rates, concentrated demand at peak times, limited use of call-back functionality, and prolonged call handling times. In response, the practice implemented an improvement plan focusing on introducing call-back functionality, reviewing the appointment system, prioritising access during peak periods, and strengthening care navigation. Clear success measures were defined. Improvements had been made, including increased availability of pre-bookable appointments and additional capacity following bank holidays. However, patient feedback indicates ongoing challenges with accessing the practice by phone at 8am, alongside limited awareness of the new booking options. Practice leaders planned to address this through improved patient communication within the practice. The National GP Survey results for 2025 were generally positive.

People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.

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 were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Care plans reflected physical, mental, emotional, and social needs of patients including those related to protected characteristics under the Equality Act. Our review of clinical records showed patients were supported to understand their condition and were involved in planning for their care needs. They were also involved in decisions about their care. This was supported by the National GP Survey which showed that 95% of respondents stated that during their last appointment they were involved as much as they wanted to be in decisions about their care and treatment. This was comparable with the national average of 91%.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

We saw the practice worked in partnership with other services to meet the needs of its patient population. The practice had tailored its services to meet the diverse needs of its community, for example, building relationships with community groups to promote the take up of screening programmes. There were established mechanisms for engaging with the community healthcare provider.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Information to promote the take up of screening and immunisation programmes was available in a range of languages. The practice had access to interpreter services, including British Sign Language. Information provided by the service met the Accessible Information Standard. Patients were informed as to how to access their care records.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatmentand support. However, complaints were not consistently managed in line with the practice’s policy. They did not always tell people what had changed asa result of their complaint.

Complaints were not consistently managed in line with the practice’s policy. While complaints and significant events were discussed at regular meetings, the complaint documentation we reviewed lacked sufficient detail, including escalation options (such as the Parliamentary and Health Service Ombudsman), root cause analysis, patient feedback following the investigation and evidence of completed learning actions. Staff we spoke with however, were able to provide information from learning from events and complaints and of changes made as a result ofpatient feedback.

The service made sure that people could access the care, supportand treatment they needed when they needed it.

People could access the service to suit their needs for example online, in person and by telephone. Treatment rooms were available on the ground floor, and a ramp and automatic door had been fitted to the entrance.

National GP Patient Survey 2025 results were positive overall. Patient experience exceeded local and national averages in several areas, including ease of telephone access (74% when compared with the local average of, 57% and 53% national), ability to choose appointment time (78% when compared with the local average of, 56% and 54% national), and overall experience (84% when compared with the local average of, 78% and 75% national).

In response to the National GP Patient Survey data and from feedback from members of the community the provider had identified changes to further improve access to the service. The service performed a telephone audit in December 2025. This identified average monthly demand of 3,758 calls, with peaks in the morning causing system pressure. Key issues included high abandonment rates and long call handling times. Improvements included call-back functionality, appointment system review, and enhanced care navigation. While access had improved, some patients remained unaware of changes, such as the prebookable appointment slots. The practice leaders advised they would put additional information in the waiting area for patients on these changes.

We received 12 patient comments through our Give Feedback on Care service. Most were positive but less positive comments regarding access focused on contacting the practice at 8am and appointment availability.

We reviewed the appointment log and found that waiting times for a routine appointment was a week, for preferred GPs this could be up to 2 weeks. For more urgent appointments, people could call for on the day appointments. The service had a duty doctor system to support with triage for on the day appointments.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, supportand treatment in response to this.

Feedback provided by people using the service, both to the provider as well as to CQC, was generally positive. Staff treated people equally and without discrimination. Leaders proactively sought ways to address any barriers to improving people’s experience and worked with local organisations, including within the voluntary sector, to address any local health inequalities. Staff understood the importance of providing an inclusive approach to care and made adjustments tosupport equity in people’s experience and outcomes. The provider had processes to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people and Travellers. Staff used appropriate systems to capture and review feedback from people using the service, including those who did not speak English or have access to the internet.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Our records review showed people were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. This information was shared with other services when necessary.