Moss Street Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Leaders and staff had a shared vision and culture based on openness, fairness, respectand accountability. We identified gaps in some systems and processes. These included, incident and complaints documentation, recruitment checks, and patient triage systems, where documented guidance to support staff was limited. There were gaps in environmental maintenance records and in the documentation of risk assessments for emergency medicines not held by the practice.

Current service 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. During this period, staff reported experiencing extremely challenging behaviours from a former healthcare professional, which contributed to significant staff attrition. Remaining staff were offered a range of wellbeing support. Following these changes, staff described an improvement in culture, highlighting positive support from GP partners and the newly appointed practice manager. Governance structures and lines of accountability had been further developed to strengthen oversight and support effective management, to mitigate risks of reoccurrence.

Leaders were visible, knowledgeableand supportive, helping staff develop in their roles. Staff at the time of the assessment felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to innovate.

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 had a shared vision, strategyand culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

All staff had contributed to the development of the new practice vision and strategy. The mission was to provide an appropriate and rewarding experience for patients whenever they need their support. They identified their core values as openness, fairness, respectand accountability. Staff described it as open, caring, professional and supportive.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told usthe current leaders in the practice were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had established Freedom to Speak up arrangements. Staff were aware of how to raise concerns and an example where staff had used the arrangements in place to positive effect.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued, for example we saw support for reasonable adjustments for staff with protected characteristics were in place.

The service had clear responsibilities, roles and systems of accountability or good governance. However, they did not always act on the best information about risk, performanceand outcomes, or share this securely with others when appropriate.

Staff were able to access the required policies and procedures via the practice’s electronic shared drive, with printed copies also available for those who preferred this format. Leaders had completed annual appraisals for staff, with remaining appraisals scheduled. GPs undertook regular peer reviews of consultation records, alongside ongoing non-medical clinical competency reviews for staff.

As a small team, the servicedemonstrated clear roles, responsibilities, and systems of accountability, with an overall understanding of good governance. However, we identified gaps in some systems and processes. These included, incident and complaints documentation, recruitment checks, and patient triage systems, where documented guidance to support staff was limited. There were gaps in environmental maintenance records and in the documentation of risk assessments for emergency medicines not held by the practice. Leaders responded positively to our findings and took prompt action where possible.

Leaders held regular practice meetings with staff, following a structured agenda, during which clinical concerns and emerging risks were discussed. Staff demonstrated a clear understanding of patient confidentiality and information security.

The newly appointed practice manager had reviewed and updated policies with oversight from clinical staff, and all staff were able to access the required policies and procedures.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes.

The practice was supported by a proactive Patient Participation Group (PPG). The PPG acted as a conduit for communication between the local community and the service. There were nine active PPG participants. Some members of the PPG were active with the local community and linked with local community groups. The service had awareness of their patient demographics and noted the practice may benefit from the addition of a virtual PPG group which may encourage the engagement and involvement of younger and working age patients too in order to ensure an inclusive approach to the patients’ voice and feedback.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The practice had a quality improvement plan in place to help drive improvements in services This focussed on the appointment system. All staff were encouraged to put forward and test out new ways of working. Staff told us they were supported with education and opportunities for career progression.

The new practice manager had implemented a business development plan covering the period 2026 to 2029, which outlined its key goals and objectives. This included a considered succession plan. At the time of the assessment, there were 2 GP partners (one male and one female), with plans to recruit an additional GP partner in 2026. The practice demonstrated a commitment to future IT innovation and had established positive working relationships with the Cannock North Primary Care Network. Additionally, one GP partner was planning to become a GP trainer.

Leaders identified higher staff turnover among administrative and reception staff and recognised the need to establish greater workforce stability. Staff described a positive cultural shift following recent changes, reporting a more relaxed and supportive working environment. Staff spoken with were positive about the improved team culture.

The practice had implemented a three-year strategic plan, which considered capacity and was aligned to projected patient need. Activity was planned to ensure sufficient resources were in place to meet both immediate and longer-term clinical demand. The plan had been agreed by the GP partners and practice manager, with the wider team kept informed through regular updates.