Moss Grove Surgery - Kingswinford

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

We looked for evidence that people were protected from abuse and avoidable harm.

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

However, the service was in breach of legal regulation in relation to safe care and treatment as not all systems and processes for medicines management were operating effectively. We have asked the provider for an action plan in response to our concerns.

This service scored 69 (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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. The provider had processes for staff to report incidents, near misses and safety events. The practice had a significant events policy, and a reporting form was in place, which was accessible to all staff members.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Information reviewed demonstrated that people had opportunities to provide feedback, and they knew how to make a complaint. Lessons were learnt from individual complaints and shared with the practice team to improve the quality of care.

The practice carried out an annual review of complaints and significant events. There had been 38 significant events and 44 complaints investigated in a 12-month period. The practice used this to identify any recurring themes, trends, learning points, and opportunities for quality improvement.

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 to ensure all patient information including laboratory test results and referrals were reviewed and actioned in a timely manner. Referrals to specialists and urgent services, including 2-week-wait (2WW) referrals, were managed through a clear process.

The provider was part of the Primary Care Network (PCN) and attended regular meetings with other agencies across the locality to share and discuss information relating to patient care and treatment. There were a range of structured meetings in place. These included safeguarding, multi-disciplinary and practice team meetings.

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 harm and 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 register of vulnerable people and acted on concerns working in partnership with other organisations.

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 harm and neglect. The service shared concerns quickly and appropriately.

There were designated safeguarding leads for both children and adults across the practice. Arrangements covered both practice sites and included clinical and non-clinical staff. Staff were aware of their safeguarding responsibilities and knew who to contact if they identified or suspected a safeguarding concern.

Monthly safeguarding meetings were held with the midwife, health visitor, and school nurse. Safeguarding issues were reviewed regularly, information was shared appropriately, and vulnerable patients were correctly coded and recorded on safeguarding registers.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

A clinician had completed enhanced Basic Life Support (BLS) training and was qualified to deliver this training to all practice staff, including as part of the induction programme for new employees. We found all staff were trained in basic life support and staff could recognise a deteriorating patient. They knew of the action to take if they encountered a deteriorating or acutely unwell patient and had been given guidance on identifying such patients. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Emergency equipment was available and maintained.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety assessments and procedures were in place to effectively manage risks across both practice sites. A health and safety assessment was due to be conducted by an external provider in July 2026; however, this was delayed and unable to take place until August 2026. In the interim, the practice completed a premises risk assessment and an annual health and safety review in July 2026 to maintain oversight of health and safety arrangements.

Regular monitoring was in place to ensure guidelines were adhered to and all staff had been made aware of the appropriate procedures to follow.

Staff had been provided with training in health and safety related topics such as fire safety, infection control, basic life support and resuscitation training. There were policies and procedures in place for the management of health and safety. Fire safety policies were in place, and staff were aware of how to access these. Systems were in place for the regular checks of fire alarms, extinguishers and fire evacuation procedures. A fire risk assessment had been completed in May 2026.

The practice had completed assessments in place for the control of hazardous substances (COSHH). Evidence provided by the practice showed equipment was regularly calibrated and electrical items were PAT (portable appliance testing) tested.

There was a business continuity plan in place which was monitored and reviewed. Reception and administration staff who handled calls to the practice and arranged appointments with the clinical team were aware of potential red flag symptoms. Staff knew when to notify a GP or other clinicians with concerns about a patient who may be acutely unwell and/or deteriorating.

During our site visit we found both of the premises were well maintained. The provider detected and controlled potential risks in the environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular checks were carried out on the premises, facilities and the equipment provided. Contracts were in place to ensure the premises were clean and well maintained.

The service generally ensured there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. However, some recruitment processes required strengthening to ensure full compliance with recruitment requirements.

There were a range of clinical and non-clinical roles within the practice such as urgent care practitioners, GPs, GP assistants, pharmacists, nurses, and reception and administrative staff. We found training was up to date, learning needs and development of staff was managed appropriately. Staff were working within their agreed areas of competence with audits undertaken.

The practice had recruitment policies and procedures in place. We found that Disclosure and Barring Service (DBS) checks had been completed, and annual declarations or risk assessments had been undertaken where required. However, during our review of personnel records, we found that some staff files did not contain evidence of identification. We also identified gaps in the recording of immunisation status. For example, while some staff had completed self-declarations regarding their immunisation status, evidence of immunisation status was not consistently available for either clinical or non-clinical staff. The practice informed us that its recruitment processes were already under review and that work to address gaps in immunisation records was underway. These issues had been identified by the practice prior to our assessment.

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 completed training relevant to their roles. Staff were aware of the systems and processes required to ensure clinical specimens were handled safely.

The practice had IPC policies in place, which were accessible to staff. An infection control audit was completed in the last 12 months to identify potential risks and ensure appropriate action was taken where required. At the time of the assessment, the practice had achieved 96% overall compliance with actions completed such as wall mounted soap dispensers. Cleaning schedules were in place, and the environment was visibly clean, well maintained and appropriately equipped to support safe care.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

As part of our assessment, we carried out remote searches of clinical records to check how the practice monitored patients’ health in relation to the use of high-risk medicines.

Clinical searches identified 2 out of 118 patients prescribed Methotrexate for the treatment of autoimmune conditions were overdue monitoring. We reviewed 5 records and found that all these patients had the required monitoring within the last 12 weeks.

A second search showed the number of people who had been prescribed warfarin (a medicine used to treat and prevent blood clots) who had not had monitoring in the past 3 months. The search identified 56 out of 72 patients on these medicines who were overdue monitoring. We reviewed 5 clinical records and found 4 people did not have an up-to-date International Normalised Ratio (INR is a blood test thatmeasures how long it takes for your blood to clot).

We reviewed patients with a potential misdiagnosis of chronic kidney disease (CKD) stages 3, 4 and 5. Our search identified 94 patients. We reviewed 5 clinical records and found that 1 patient required further monitoring and 3 patients had not been coded appropriately as CKD 3.

Our remote clinical searches found 1695 patients had received a medication review in the previous 3 months. We reviewed a random sample of 5 records and found thorough medicine reviews had been completed.

The practice worked with the clinical pharmacists from the local Primary Care Network (PCN) to monitor people and the prescribing of medicines. All safety alerts were sent to the clinical pharmacists to disseminate the information. There was a process in place for managing safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA); however, we identified shortfalls in the implementation and follow-up of some alerts. For example, we carried out a clinical search relating to patients prescribed SGLT2 inhibitors (sodium-glucose co-transporter-2 inhibitors), a class of medicines used to lower blood glucose levels. The search focused on known risks associated with these medicines, including diabetic ketoacidosis (DKA) and Fournier’s gangrene. Our search identified that 354 of 485 patients prescribed these medicines had no documented evidence that they had been advised of these risks. We reviewed 5 patient records and found no evidence that the relevant safety information or advice had been provided.

We discussed the concerns identified through our clinical searches with the provider, who responded positively and demonstrated a clear commitment to addressing the issues identified. The provider had already begun taking action and had developed an action plan and timeline to ensure the deficiencies were addressed, including reviewing affected patients and strengthening processes to support medicines management.

The practice utilised Patient Group Directions (PGDs) to ensure the safe administration of immunisations and all documentation was properly authorised and signed. Staff managed prescription stationery appropriately and securely.

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. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

Prescribing data reviewed as part of our assessment showed that the practice’s performance was in line with national averages for pregabalin and gabapentin, psychotropic, hypnotic and antibiotic medicines.