During an assessment under our new approach
Date of Assessment: 2 July 2026 to 7 July 2026. Moss Grove Surgery Kingswinford is a GP practice and delivers service to 18,637 patients under a contract held with NHS England. A branch location for this practice is located in Kinver. The National General Practice Profiles states that 95.5% of patients registered are White, 1.9% Asian, 0.4% are Black, 1.7% are Mixed and 0.5% are Other. Information published by the Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the tenth decile (10 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
The service had a good learning culture and people could raise concerns. Managers investigated incidents and people were generally protected from avoidable harm, although improvements were required in medicines monitoring. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. However, we identified areas where governance arrangements required strengthening. In particular, there were gaps in the recording and monitoring of staff immunisation status. We also found that the monitoring of some medicines required improvement, as associated blood tests and clinical monitoring were not always completed in line with best practice guidance.
People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was not always 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 and those important to the person made decisions in the individual’s best interests when they lacked capacity.
People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.
People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was not always easy to access by telephone, and the practice was working to eliminate barriers including the promotion of the NHS app. 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.
Leaders were visible, knowledgeable, and supportive, and staff were able to raise concerns and provide feedback. Roles and responsibilities were clearly defined and well understood across the practice. Leaders worked collaboratively with external stakeholders to improve services and support innovation. They used a range of data and information to monitor risk, performance and patient outcomes; however, oversight of medicines management required strengthening. While governance arrangements were generally well established, leaders had not always ensured sufficient oversight of medicines management to demonstrate consistent alignment with current guidance and best practice. As a result, governance processes in this area required further strengthening to provide assurance that care and treatment were delivered safely and effectively.
We found a breach of Regulation in relation to Safe Care and Treatment and have requested an action plan from the provider in response to the concerns identified during this assessment. The breach was limited to aspects of medicines monitoring and governance oversight. We found governance arrangements to be generally effective in other areas of the service, with leaders demonstrating openness, responsiveness and a commitment to continuous improvement. Following feedback during the assessment, leaders acted promptly to address the issues identified and implemented plans to strengthen oversight and monitoring processes.