High Oak Surgery

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.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

Systems were in place to protect individuals from abuse and avoidable harm, with safety clearly prioritised across the service. The provider responded seriously to concerns, and feedback from people using the service indicated they felt safe and well cared for. Safety incidents were investigated, and learning was used to identify shortfalls and prevent recurrence.

Safeguarding procedures were well established to protect those at risk, and services were designed around individuals to support safe transitions between care settings. People were supported to understand their care, enabling informed choices that reduced the risk of harm.

Leaders ensured there were sufficient numbers of appropriately skilled staff in place to deliver safe care. Pre-employment checks were completed, and staff received safeguarding training relevant to their roles, alongside regular appraisals, and ongoing training to maintain high standards.

Health and safety procedures were in place, and the premises were appropriately maintained. Systems for monitoring patients’ health in relation to medicines, including those requiring regular review, were effective.

This service scored 75 (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. Meetings were held so that teams discussed and learnt from clinical issues, complaints, or incidents. Staff described an open and transparent culture, with safety identified as a key organisational priority. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Clear processes were in place for reporting incidents, near misses, and safety related events. These issues were routinely discussed and contributed to governance oversight through integration with the wider Trust's reporting and review systems.

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. We found clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. There was a system in place to ensure all patient information including documents, laboratory test results and referrals were reviewed and actioned in a timely manner. Referrals and test results were managed in a timely way.

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, for example, people on the practice palliative care register.

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. For example, the provider regularly liaised with multi-disciplinary teams to coordinate the care for elderly residents living in care homes.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a register of vulnerable individuals and responded proactively to concerns, implementing actions and learning in collaboration with partner organisations.

Safeguarding was reviewed, and relevant information was shared amongst the team. Vulnerable patients were appropriately coded, and safeguarding registers were maintained. Specific coding protocols were followed for individuals identified as being at risk of domestic violence who accessed the NHS App.

Following the practice takeover by The Dudley Group NHS Foundation Trust, all the practice’s internal policies were aligned with the Trust policies to ensure consistency, accountability, and ongoing quality improvement.

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.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

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

The building was managed by Community Health Partnerships and accommodated a range of NHS services. Regular building user group meetings were held to discuss matters relating to security, maintenance, and health and safety arrangements. The Pensnett site which operated 2 days per week on Tuesday and Thursday afternoons was managed by NHS Property Services. For both sites, contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken by the practice and risks identified had been addressed. There was a fire safety policy in place and regular checks were undertaken. We saw that all staff had completed mandatory training in fire safety. Fire marshals were appointed, and the practice had carried out fire drills in the last 12 months. There was a business continuity plan in place which was monitored and reviewed.

The service made sure there were qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. At the time of our assessment the provider was actively recruiting additional clinical and non-clinical staff members to support shortfalls in this area. In addition, there were plans to host medical students. Staff reported that additional recruitment would ease workload demands.

There were a range of clinical and non-clinical roles within the practice. We found training was mostly up to date and learning needs and development of staff was managed appropriately. Policies and processes were in place for auditing and supervising clinical staff, who we found were working within their agreed areas of competence.

The Trust maintained recruitment policies aligned with safer recruitment standards. New staff participated in a structured induction programme and were required to complete mandatory training within designated timeframes. Staff were supported to deliver safe care through access to relevant training, development opportunities, and clinical supervision.

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 lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. At the time of this assessment, The Trust had completed an infection control audit in July 2025 with an overall score of 92.5% for High Oak Surgery and 83.7% for High Oak Pensnett Satellite GP Surgery. An action plan was currently in place and was being reviewed at the time of our site visit to ensure compliance.

The service ensured medicines and treatments were safe and tailored to people’s needs, capacities, and preferences. People were involved in planning their care, including when changes occurred. Staff supported individuals in reviewing their medicines and helped them understand how to manage them safely. People knew what to do and who to contact if their condition worsened or they experienced unexpected symptoms.

Staff followed clear procedures to make sure people taking higher risk medicines underwent the required checks and monitoring. Staff followed processes to ensure medicines with specific risks were monitored appropriately and prescribed to optimise care outcomes, including antibiotics. We reviewed clinical records for patients who had been prescribed other medicines that required routine monitoring. Our review showed that overall medicines were managed safely and the approach to medicines reflected current and relevant best practice and professional guidance.

Staff felt confident managing the storage, administration, and documentation of medicines. Prescription stationery was handled securely. Stock levels and expiry dates were routinely checked for all medicines, including emergency medicines, vaccines, and controlled drugs. Medical gases, such as oxygen, were stored safely and fridge monitoring checks routinely undertaken. All Patient Group Directions (PGDs) we looked at were in date and appropriately authorised.

The provider had effective systems for managing safety alerts and there was a regular programme of clinical audits to support safe prescribing and improved care.