Moss Street Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The service had developed a good learning culture and people could raise concerns. However, the documentation reviewed for both significant eventsand complaints lacked sufficient detail, with limited evidence of the root cause analysis and the learning actions undertaken or embedded in practice. The facilities and equipment met the needs of people and were clean. However, gaps were identified in some areas of maintenance documentation. These were fed back to the practice for action and risk mitigation. We reviewed the emergency trolley, defibrillator and oxygen, all of which were within their expiry dates. However, for medicines not routinely held by the practice and for equipment not in place, there was no documented risk assessment to support this decision. The clinical team advised that this would be addressed and actioned immediately. Some gaps were identified in recruitment records. Prescription security arrangements were partially in place, with printer prescriptions logged on receipt; however, no serial number log was maintained to enable effective audit and tracking. Documentation in the medication reviews we sampled were limited to a single-line entry stating that a medication review had been completed. As a result, the quality and comprehensiveness of these reviews could not be assessed due to a lack of supporting detail. The service was in the process of recruiting 2 additional reception staff and once recruited there were enough staff with the right skills, qualificationsand experience. Managers made sure staff received training and regular appraisals to maintain high-quality care.

Some medicine monitoring gaps were identified through our clinical searches, and these were fed back to clinical staff for actioning.

Leaders had responded to recent risks linked to identified incomplete documentation from former personnel which had prompted a significant programme of focused patient record audits to ensure any risks were identified and mitigated. Commissioners, the Care Quality Commissionand the General Medical Council had been informed of their findings. Our clinical searches of medicines requiring regular monitoring were largely satisfactory. However, some exceptions were identified, including one patient prescribed despite abnormal results and lack of engagement, a potential absence of a shared care agreement, and patients on high‑risk medicine combinations without appropriate gastroprotection.

This service scored 59 (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 had a proactive and positive culture of safety based on openness and honesty. However, this was not always well documented such as evidence of the root cause analysis investigations for significant eventsand complaints.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. A representative from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. For example, the introduction of a prebookable appointments following patient feedback on telephone system. The leadership including the new practice manager encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues.

Staff we spoke with felt the last few months there was a positive shift towards a more open culture and that safety was a top priority.

The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. We reviewed a random selection of significant eventsand complaints and found documentation to support the analysis of significant eventsand complaints lacked detail and trends in significant eventshad not been completed. Staff we spoke with were able to provide verbal information on the actions taken and that the learning from incidents and complaints had resulted in changes that improved care for others.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harmand neglect. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Systems to corroborate the practice list of vulnerable people with the wider multi-disciplinary team were not in place but had been attempted. The provider had evidence they had regularly invited health and social care professionals to meetings.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

Most of the required emergency equipment was available and maintained. However, the 3 emergency medicines not held by the practice had no risk assessment in place. The clinical staff assured the Care Quality Commission that this would be immediately addressed.

Some staff were aware of how to recognise the rapidly deteriorating patient; however, protocols or supportive guidance were not in place for non-clinical staff to refer to. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Appropriate testing of electrical equipment and electrical hard wiring we were informed had taken place. However, the provider was unable to provide certification evidence. There had been a new gas boiler and access to servicing records.

Staff had completed fire safety training and there were named fire marshals. Fire risk assessments had been commenced with the new practice manager including the introduction of fire evacuation drills and a fire alarm testing log. The risk assessment had identified a few areas for improvement and some of these had been actioned. For example, fire blankets and new fire exit signage. The fire extinguisher checks were dated 2024 and we fed this back to the provider for actioning. Leaders actioned this during the onsite assessment. Window blinds were present in some rooms; however, there were no measures in place to mitigate the ligature risk, and no formal risk assessment had been completed. The provider gave assurance that appropriate actions would be implemented immediately. Although some equipment portable appliance tests (PAT) had been completed, we found that plugs labelled March 2025 in the electrical sockets, as well as on an extension lead. This was actioned during the assessment with PAT tests to be completed on 01 June 2026 and advised a risk assessment would be completed during the interim period.

The provider held 2 wheelchairs available for patient use. However, there was no service or maintenance records available. There was no service or maintenance record available for the hydraulic patient examination couches.

There was no system in place to check the clinical consultation rooms for the dates on items such as urinalysis sticks. Those we found to be out of date were removed.

Although there was a recent policy put in place for the use of CCTV, we found no signage to alert patients that there was CCTV throughout the practice public areas. The provider assured us this would be actioned immediately.

There was no effective system in place to ensure that large water bottles used for staff drinking water were within their expiry date. During the inspection, we identified some bottles that were out of date. The practice manager acknowledged this and advised that it would be addressed.

A Legionella risk assessment was in place, and routine monitoring checks were undertaken by an external contractor. However, at the time of the assessment, the practice did not have access to the contractor’s portal to review these checks and gain assurance of the findings. The practice manager advised that access had been requested and confirmed that relevant information from the portal would be incorporated into business continuity and governance documentation to support oversight and continuity.

A room used solely for storage contained several items of equipment that were out of date. The provider advised that these would be organised into a clearly designated area to indicate they were awaiting disposal, reducing the risk of them being inadvertently used by staff.

We found that, where risk assessments had been completed, they did not consistently include key information such as the date of completion or the responsible person. This limited the provider’s ability to ensure appropriate oversight and review.

There was a business continuity plan in place which was monitored and reviewed. All staff had been in receipt of health and safety training.

The service made sure there were enough qualified, skilledand experienced staff. The provider had previously identified, through incident reporting, that systems to ensure adequate supervision and oversight were not always in place. At the time of the assessment, the provider had implemented and embedded improvements to address this, reducing the risk of recurrence. Staff worked together well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date and our review of 4 staff records showed staff were up to date with all their required training. Learning needs and development of staff were managed appropriately, and staff were working within their agreed areas of competence. Most staff had received a recent appraisal or had a date for an appraisal planned.

Safe recruitment practices were not followed. We found there were some gaps in the documents held in some of the recruitment files we reviewed. For example, not all staff files held staff members full vaccination and immunity history, where this was not present there was no risk assessment in place. There was an absence of a full employment history in some records. Some did not hold satisfactory information about physical or mental health conditions relevant to the person’s ability to carry out their role. However, the records reviewed held references, Disclosure and Barring Service (DBS) checks, photographic identity, evidence of professional register checks and clinical staff qualifications and certificates.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control (IPC) lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed. Areas for improvement identified in the January 2026 infection prevention and control (IPC) audit were documented within the checklist; however, these had not been developed into a formal action plan with clear timescales for completion. This limited effective oversight and governance of the audit findings.

Our on-site assessment found a few minor areas for an IPC action plan which the provider assured us would be addressed.

The provider maintained a management of healthcare waste policy and links to the policy were contained in the practice IPC policy.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacitiesand preferences. They did not always involve people in planning.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment and clinical pharmacists ran regular searches to monitor the prescribing of medicines. Audit actions included the establishment of a monitoring register and a review of Essential Shared Care Agreements (ESCAs) and patient safety alerts. ESCAs are formal agreements between specialist services and GPs that support the safe sharing of care, particularly in relation to prescribing responsibilities. This was a GP-led audit, complementing routine electronic audits undertaken by the practice’s pharmacy team as an additional safeguard to ensure patients receive appropriate monitoring and review.

Our remote clinical searches identified a cohort of patients prescribed medicines requiring regular monitoring who had not received the appropriate blood tests within the required timeframe. For example, 16 patients prescribed disease-modifying antirheumatic drugs (DMARDs) were identified and 1 patient potentially lacked monitoring within the previous 6 months. We reviewed 5 patient records and found that prescribing had continued in the patient identified despite non-attendance for monitoring, although the practice had made repeated attempts to recall the patient. We also identified a potential absence of an ESCA for one patient and a lack of an appropriate clinical alert within their record. Evidence demonstrated that the practice had made reasonable efforts to contact affected patients.

Clinical searches identified 29 heart failure patients on a type of diuretic medicine with 7 potentially overdue monitoring. We reviewed 5 of the 7 records which showed satisfactory monitoring; 3 were slightly overdue, 2 by 2 months. One patient required monitoring as prescribed a high‑dose statin without monitoring having taken place.

Clinical searches identified 11 patients prescribed overactive bladder medication; 5 records were reviewed. One patient required removal from repeat prescribing. Four were overdue blood pressure (BP) monitoring, with no documented medication risk discussions. Of these, 1 was advised to book, 1 had recent BP reading at a specialist review, and two required a review.

A patient prescribed a combined oral contraceptive pill (COCP) within the last 12 months, with a history of venous thromboembolism (VTE), was identified in our clinical searches. One patient record suggested the need for an early clinical review appointment.

Our clinical searches found 53 patients over the age of 65 years prescribed an oral NSAID or an antiplatelet over 75 years with no PPI (not declined/not tolerated). We reviewed 4 of the 53 records. All had the potential increased risk of GI bleed because of age and anti-platelet. 3 of the 4 had an additional risk, 256 was lightly anaemic, 385 had a history of dyspepsia and 470 had a history of dyspepsia and h-pylori eradication in 2025. All needed a review.

Clinical searches identified 53 patients aged over 65 on oral non-steroidal anti-inflammatory drugs (NSAIDs), or over 75 on antiplatelets (medicines used in the prevention of abnormal blood clots) without a gastroprotection medicine. The 4 records reviewed showed all required review.

Documentation in the medication reviews we sampled were limited to a single-line entry stating that a medication review had been completed. As a result, the quality and comprehensiveness of these reviews could not be assessed due to a lack of supporting detail.

Our clinical search findings were fed back to the provider to support further action and strengthen oversight of monitoring processes.

There was a lack of a systematic approach for tracking printer prescription stationery throughout the practice. The practice manager advised this would be actioned immediately.

Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. There was a system to audit the prescribing on non-medical prescribers and provide clinical supervision.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. However, we found stock checks could not be completed for some medicines held for example those used in minor surgery. The provider advised this had been discussed and will be introduced. Staff stored medical gases, such as oxygen, safely. Systems were in place to maintain the cold chain for the safe storage of vaccines.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this.