- GP practice
Moss Street Surgery
All Inspections
17 November 2022
During a routine inspection
We carried out an announced comprehensive inspection at Moss Street Surgery on 17 November 2022. Clinical searches were undertaken on 22 November 2022. Overall, the practice is rated as good.
Safe - good
Effective - good
Caring - good
Responsive - good
Well-led - good
Following our previous inspection on 20 April 2015, the practice was rated good overall and for all key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Moss Street Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection due to the length of time the practice was previously rated. We assessed all key questions.
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- A site visit.
- Staff feedback questionnaires.
Our findings
We based our judgement of the quality of care at this service on a combination of:
- what we found when we inspected
- information from our ongoing monitoring of data about services and
- information from the provider, patients, the public and other organisations.
We found that:
- The practice had systems in place to keep people safe and safeguarded from abuse.
- Patients received care and treatment that met their needs.
- The practice had a system in place for managing significant events however, incidents had not always been identified as an event to improve the quality of patient care.
- There were effective systems in place to monitor patients prescribed high-risk medicines and monitoring of patients with long-term conditions.
- Staff had the information they needed to deliver safe care and treatment.
- The practice had recently obtained partial funding for renovations to the premise to enable improved accessibility for its patient population.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- A new cloud-based system had been installed in August 2020 with improved functions including call recording and additional capacity for calls.
- Staff enjoyed working at the practice and felt respected, supported, valued and encouraged to do their role.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- Processes for managing some risks were not fully embedded into practice.
- Patient satisfaction in the National GP Patient Survey 2022 was higher than local and national averages across all indicators in relation to providing caring and responsive services.
Whilst we found no breaches of regulations, the provider should:
- Review and improve recruitment procedures in accordance with regulations.
- Review and improve systems to significant events are captured to improve patient care.
- Review procedures for the oversight of monitoring vaccine fridge temperatures.
- Develop a programme of targeted quality improvement.
- Improve the documentation in response to the management of complaints.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services
20/04/2015
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr S R Gibbins and Partners on 20 April 2015. Overall the practice is rated as good.
Specifically, we found the practice to be good for providing safe, effective, caring, responsive and well-led services. It was also good for providing services for older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including those with dementia).
Our key findings were as follows:
- Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
- Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
- Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
- The practice had good facilities and was well equipped to treat patients and meet their needs.
- The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group (PPG).
There were areas of practice where the provider should make improvements:
- Expand the availability of emergency medicines to ensure that they are age appropriate.
- Introduce a method of recording cleaning activities undertaken to evidence they have taken place.
- Provide staff with regular appraisals and support personal development plans or record the reasons they cannot be met.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice