Moss Grove Surgery - Kingswinford

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• 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

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.

This service scored 67 (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, wellbeing and communication needs with them.

98% of patients that completed the National GP Patient Survey data in 2025 agreed that they felt their needs were met during their last GP appointment and 96% felt the healthcare professional they saw had all the information they needed about them during their last GP appointment. Both scores were higher than the local and national average. Following the inspection, the 2026 survey results showed a slight decline in patient satisfaction across these measures.

People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. 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. A portable hearing loop was available at reception. 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.

The provider had systems in place to identify people with previously undiagnosed conditions. Care plans and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) records were completed and reviewed regularly. Staff could refer people with social needs, such as those experiencing social isolation to a social prescriber. Systems were in place to identify individuals with caring responsibilities and all patients with a learning disability were invited to attend an annual health assessment.

There were appropriate referral pathways to make sure that patients’ needs were addressed. We found that staff had the appropriate skills and training to carry out reviews where appropriate.

The practice employed a range of non-medical staff, including an Urgent Care Practitioner whose role focused on supporting housebound and vulnerable patients with complex health needs and multiple long-term conditions. The practice had identified patients within its population who met these criteria and had established coordinated packages of care to meet their needs. This was supported through multidisciplinary working with the Integrated Nursing Team, District Nurses, the Palliative Care Team, Alzheimer’s and Admiral Nurses, and the Royal British Legion, ensuring patients received comprehensive, holistic and coordinated care.

The service did not always deliver care and treatment in line with current evidence-based guidance and monitoring requirements.

During the remote clinical review, we carried out a search to identify people with asthma who had been prescribed 2 or more courses of rescue steroids in the past 12 months. The search identified potentially 90 out of 2194 people. We reviewed a random sample of 5 clinical records and found that 2 out of 5 patients had an asthma review in the last 12 months, 1 patient had been recalled for a review and 4 out of the 5 patients had not been followed up following an exacerbation in line with clinical guidelines.

We carried out a clinical search on patients who had hypothyroidism and had not received the appropriate monitoring in the past 18 months. The search identified potentially 70 out of 942 people. We reviewed the 5 clinical records and found all 5 patients were overdue monitoring. Although each patient had been recalled, no further action had been taken, such as limiting repeat medication supplies pending review.

Our remote clinical search identified the practice had 110 out of 1298 patients with diabetes who’s latest HbA1c (blood glucose) level was consistently high. We reviewed 5 patients and found appropriate monitoring in place.

We carried out a clinical search on patients prescribed Bisphosphonates for 5 years or more to determine whether a review had been carried out (these are medicines used to strengthen bones, prevent fractures, and slow down bone loss). The search identified 140 patients. We reviewed 5 clinical records and found appropriate action had been taken.

Further reviews of the clinical system identified people with chronic kidney disease (CKD) 4 and 5 who had not received monitoring in the last 9 months. The search identified 5 out of 78. We reviewed 5 clinical records and found 1 patient had been recalled and 4 were overdue urea and electrolyte monitoring.

Overall, we found the remote clinical searches we undertook demonstrated the monitoring of patients with long-term conditions had not always followed the National Institute for Health and Care Excellence (NICE) recommendations. We discussed these findings with the provider, who responded positively and took prompt action to address the areas of concern and implement improvements where shortcomings had been identified.

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 told us that they had access to the information they needed to appropriately assess, plan and deliver people’s care, treatment and support and they had enough information to plan and refer people and receive subsequent results and information following referral. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

There were systems and processes in place to enable information to be shared between the provider and services to ensure continuity of care. There were regular meetings with multi-disciplinary teams to co-ordinate and plan care effectively.

The Primary Care Network (PCN) helped to support the practice by providing links to pharmacists, physiotherapists and social prescribers. People were able to receive co-ordinated care between the practice and the PCN.

The service supported people to manage their health and wellbeing to maximise their independence, choice and 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. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity and patients were encouraged to take an active role in reviewing their health and were given support to recognise changes.

Health promotion material was observed in the practice, and further information could be found on their website that supported national priorities and initiatives to improve population health by supporting people. The practice delivered health promotion events in coordination with the Primary Care Network (PCN) such as a wellbeing fair, cancer events, men’s health event and a migrant community health event.

The practice had made reasonable adjustments to provide support to vulnerable patients. This included home visits for patients who were unable to attend the practice.

The service routinely monitored people's care and treatment. However, outcomes were not always in line with national targets across all areas.

The practice was performing above the national averages for bowel, and breast screening. Cervical screening rates were below the national target of 80% uptake with the practice having achieved 72.9% for people aged between 25 to 49 years of age. They had achieved 73.3% target for people aged 50 to 64 years. Childhood immunisation ranges were above the target with ranges between 96% and 97%.

Leaders continued to engage with patients to encourage attendance at appointments. The practice had implemented a range of targeted initiatives in coordination with the Primary Care Network (PCN), including health promotion events focused on skin cancer awareness, prostate cancer, and cervical screening. The practice was also working closely with Public Health to improve screening uptake and delivering proactive outreach to patients to support engagement with preventative healthcare services.

The practice had a programme of clinical and non-clinical audits and action plans aimed at driving continuous improvement in patient care and operational efficiency. For example, the practice had completed a Gabapentin and Pregabalin prescribing audit, as well as an audit reviewing the use of Rosuvastatin in patients with severe renal impairment.

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. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.