Background to this inspection
Updated
10 August 2023
Moss Way Surgery is located in Liverpool at:
51-53 Moss Way
Liverpool
L11 0BL
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury.
The practice is situated within the NHS Liverpool Integrated Care System (ICS) and delivers a General Medical Services (GMS ) contract to a patient population of about 2,400 patients. This is part of a contract held with NHS England.
The practice is part of a wider network of GP practices, the North Liverpool Primary Care Network (PCN)
Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in decile one (1 out of 10). The lower the decile, the more deprived the practice population is relative to others. A lower level of deprivation can indicate challenges in providing healthcare. The supply of healthcare services tends to be lower in more deprived areas due to a number of factors but has an increased demand. The population tends to have poorer health status among individuals with a greater need for health services. For example, there may be higher levels of long-term conditions such as those affecting the cardiovascular system and respiratory system. This practice has a higher than local and national average prevalence of chronic obstructive pulmonary disease, obesity, cardio vascular disease and diabetes.
According to the latest available data, the ethnic make-up of the practice area is 94.5% White, 2.4% Asian, 1.6% Black, 1.1% Mixed, and 0.4% Other.
The age distribution of the practice population contains more older people than the local and national averages.
The practice has one lead GP supported by a partner GP who covers in absence. The practice also has one part time nurse and a team of reception/administration staff. The nurse is also the practice manager.
The practice is open between 8am – 8pm Monday and 8 am to 6.30pm Tuesday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.
Out of hours services are provided by PC24 and accessed through NHS111.
Updated
10 August 2023
We carried out an announced comprehensive at Moss Way Surgery on 3 and 4 July 2023. Overall, the practice is rated as good.
Safe - requires improvement
Effective - good
Caring - good
Responsive - good
Well-led - good
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Moss Way Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection in line with our inspection priorities. The service has not been inspected and rated since change of registration in December 2022.
To get to the heart of patients’ experiences of care and treatment, we ask the following five questions:
- Is it safe?
- Is it effective?
- Is it caring?
- Is it responsive to people’s needs?
- Is it well-led?
These questions therefore formed the framework for the areas we looked at during the inspection.
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 short site visit.
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:
- Improvements were needed to the way the practice kept patients safe and protected them from avoidable harm.
- Some fire safety systems were lacking. Fire evacuation drills did not take place.
- Infection prevention and control audits identified actions that needed attention such as replacing carpets and curtains.
- Emergency medicines were not suitable and there was no evidence of checks being undertaken of emergency medicines and equipment such as oxygen.
- Staff had not undertaken formal training in identification and management of sepsis.
- Patients received effective care and treatment that met their needs.
- Cervical cancer screening was below the 70% target.
- There were sufficient staff who were suitably qualified and trained.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice understood its patient population and adjusted how it delivered services to meet the needs of its patients.
- Patients could access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
We found a breach of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to patients.
In addition, the provider should:
- Improve prescribing practice for certain medicines including pregabalin/gabapentin and psychotropics.
- Improve the uptake of eligible people for cervical cancer screening.
- Improve the uptake of childhood immunisations.
- Improve the monitoring of patients with asthma who are prescribed recurrent steroid rescue packs.
- Implement an annual audit plan or programme based on local, national and service priorities.
- Implement an annual appraisal system for all staff.
- Implement equality and diversity training for all staff.
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 Health Care