Moss Grove Surgery - Kingswinford

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• 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

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

At our last assessment, we rated this key question as Outstanding. At this assessment, the rating has changed to Good.

Whilst we identified a breach of Regulation 12 relating to medicines monitoring, we found leaders had established governance systems that were effective across most areas of the service. The governance concerns identified were isolated to specific areas of oversight rather than indicative of widespread governance failure. Leaders responded positively to the findings and took prompt action to address the identified risks.

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, strategy and culture. Its aim was based on providing high quality healthcare, in a personalised, efficient, accessible and timely fashion, taking into account the needs of their patients and the local population, whilst at the same time being mindful of the use of NHS resources. The practice showed awareness of the challenges and changing needs of their local population and worked collaboratively with services to ensure positive outcomes.

The practice was led by a 5 GP partners operating through a board level governance structure. Staff demonstrated a clear understanding of their own roles and responsibilities, as well as those of their colleagues, with well-defined lines of accountability across the organisation. The practice had a business development plan and a clear vision for its future direction. This set out key priorities, succession arrangements, and actions to support long-term sustainability, while maintaining the delivery of high-quality, patient-centred care. The practice had systems, processes and information in place to monitor and manage current and future performance.

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.

GP Partners met regularly, operating within a shared leadership model that promoted collective accountability and collaborative decision-making. The leadership team worked with other practices in the Primary Care Network and was engaged in the development of primary care services within the local area.

Throughout the inspection, leaders demonstrated openness, self-awareness, and a genuine commitment to addressing identified areas for improvement. They took immediate ownership of the findings discussed at feedback regarding the clinical searches. They engaged constructively with the inspection process and moved quickly to mitigate identified risks during and immediately following the on-site assessment and were committed to addressing these issues as part of the post-inspection response.

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. Feedback from staff showed that they knew how to access relevant policies and procedures, including the whistleblowing policy, and were aware of the nominated Freedom to Speak Up Guardian who could support them to raise concerns. There were opportunities for staff to provide feedback on how the service was operating. These included regular meetings and annual staff surveys. Leaders encouraged staff to speak with the management team about any concerns or ideas for improvement.

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

Policies and procedures to promote diversity and equality were in place and all staff had completed equality and diversity training. All staff had access to regular appraisals, one to ones, team meetings, coaching, and mentoring. There was an induction process in place for new staff and training available. The majority of staff told us they felt supported and were confident in seeking advice and guidance when needed.

The service had clear responsibilities, roles, systems of accountability, however some areas within good governance required strengthening in the management of medicines monitoring and staff immunisation status. Whilst governance systems were well established and effective across most areas of the service, they had not always identified or addressed gaps in medicines monitoring and staff immunisation records. These issues represented weaknesses in governance oversight rather than a widespread failure of governance systems, and leaders had already commenced actions to address the concerns identified.

Leaders and managers provided effective support to staff, all of whom demonstrated a clear understanding of their individual roles and responsibilities.

The provider used data to monitor performance and drive improvements. Regular searches of the clinical records system were conducted to identify patient needs and ensure appropriate care was provided. However, our review of clinical records indicated that these processes were not always fully effective. Greater consistency was required in the monitoring of patients prescribed medicines to ensure that necessary blood tests and reviews were completed in a timely manner.

Staff had regular opportunities to discuss incidents, complaints, safeguarding concerns and the management of patients with complex needs. Leaders had established systems to ensure that learning from complaints and incidents was embedded into practice and that appropriate actions were implemented.

Staff were aware of the designated leads for key areas, including safeguarding, infection prevention and control, and significant event monitoring. They also had access to all relevant policies and procedures.

The practice used digital systems securely and effectively, with appropriate arrangements in place to maintain the availability, integrity and confidentiality of data and records. Staff took patient confidentiality and information security seriously.

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 partake in health initiative events such as skin cancer awareness, breast screening, Men’s health and gambling support.

Staff made adjustments to improve coordination of their service with community healthcare services, including through established multi-disciplinary meetings centred on the care of those at higher risk of hospital admission or those vulnerable.

The practice provided care to 3 residential care homes. We spoke with representatives from the care homes, who reported a positive working relationship with the practice and that they had seen improvements in their responsiveness for their residents.

A GP worked collaboratively with the Patient Participation Group (PPG) to provide updates, gather feedback from patients, and use this information to inform service improvements. We spoke with a PPG member who told us they valued the attendance and involvement of a GP at meetings, although they felt greater participation from non-clinical staff would also be beneficial. The PPG had contributed to a range of initiatives aimed at supporting the practice, including patient surveys, providing feedback on access and appointments, assisting with the practice newsletter, and supporting the flu vaccination campaign. At the time of our assessment, the PPG was planning to strengthen links with other local PPGs and was working with the practice to gain a better understanding of its operational processes; enabling them to communicate more effectively with the wider patient population.

The provider worked closely with community services and voluntary organisations to support patients' health and wellbeing needs, including those living with Alzheimer's disease and dementia. The practice also worked with organisations such as the Royal British Legion to provide additional support for patients where appropriate. In addition, the practice organised charity and fundraising events to support a range of local and national causes, demonstrating its commitment to the wider community.

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 and contributed to safe, effective practice and research.

The leadership team held regular staff meetings to share learning from incidents and complaints and monitor the quality of the services provided. They also worked collaboratively with stakeholders to improve the experience of people using the service and to support the wider needs of the local community.

The practice operated as a training practice. In addition, the practice was actively involved in research and participated in a range of studies, including DaRe2THINK and projects supported by the National Institute for Health and Care Research (NIHR). Research activity included studies focused on the management of atrial fibrillation and anticoagulation, as well as the monitoring of infections, disease progression, and therapeutic interventions.

At the time of our assessment, the practice was reviewing opportunities to improve environmental sustainability. It had appointed a Green Champion to lead and promote initiatives aimed at reducing single-use plastics, increasing recycling, minimising food waste through composting, supporting local wildlife and biodiversity, promoting inhaler recycling, and improving energy efficiency across the surgery.

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