Moss Way Surgery

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