The Care Quality Commission
  • Doctor
  • GP practice

City Square Medical Group

Overall: Requires improvement read more about inspection ratings

14 Deancross Street, London, E1 2QA (020) 7488 4240

Provided and run by:
City Square Medical Group

Important: This service was previously registered at a different address - see old profile

All Inspections

During an assessment under our new approach

We carried out an announced assessment of City Square Medical Group Centre from the 15 May to 4 June 2024. We carried out this assessment to follow up the breaches of regulation 12 (safe care and treatment) and 17 (good governance), found in the previous inspection carried out from May to July 2023 where the practice was rated inadequate overall and in the key questions safe, effective, and well led. This assessment reviews the key questions for safe, effective, and well led. A further assessment is planned for the review of the key questions caring and responsive. During the assessment we found that: The leaders had implemented new systems, practices, and processes to keep people safe. The practice had systems in place to manage risks to patient safety. The practice had an effective system in place to ensure the appropriate and safe use of medicines. The practice learned from significant events. The leaders had improved the environment. Patients were regularly assessed, and care and treatment were delivered in line with current legislation and evidence-based guidelines. The leaders monitored patients care and outcomes monthly to ensure they were met. Following the previous inspections leaders changed the governance at the practice and introduced a safety and quality and partner meetings, which had implemented and reviewed the improvement plan and risk register, monitored performance and managed risk. The leaders had worked with staff to develop a shared direction and culture. However, prior to the assessment the leaders had not identified a number of outstanding tasks in the patient record system, once identified they immediately responded. Although the leaders were trying to recruit new staff, staff told us there were not enough reception staff to enable ease of access, this will be assessed at a further assessment. Due to the improvements, we have found during this assessment we have removed the practice from special measures.

24 May 2023, 7 and 23 June 2023 (on site), 12 and 21 July 2023 remote evidence review.

During a routine inspection

At a previous inspection on 9 May 2017 when the practice was registered at a different location, it was rated good in all key questions and overall, and there were with no regulatory breaches.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for the City Square Medical Group on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out a comprehensive unannounced inspection of the City Square Medical Group on 24 May 2023, 7 and 23 June 2023 (on site), and 12 and 21 July 2023 (remote evidence review), to follow up concerns reported to us.

Overall, the practice is rated as inadequate. The key questions are rated as:

Safe - inadequate

Effective - inadequate

Caring - requires improvement.

Responsive - requires improvement.

Well-led - inadequate,

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.
  • Site visits.

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:

  • Clinical staff were working outside the scope of their role and competence which exposed patients to a risk of harm.
  • Examples of unsafe clinical care included treatment relating to regarding long term conditions, childhood immunisations, contraceptive pill checks and cervical screening.
  • The practice had not ensured effective medicines management which exposed service users to the risk of harm, including emergency medicines, prescriptions security and refrigerated medicines.
  • Staff had administered injectable medicines, including a controlled drugs outside required legal frameworks. There were no effective arrangements for the oversight of clinical care.
  • Arrangements for the prevention and control of infections were ineffective and standards of cleanliness were not met.
  • Patients did not always receive effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care, but their privacy and dignity were not always sustained.
  • Patients could access care and treatment in a timely way, but patients’ complaints and feedback were not gathered and acted upon to improve services.
  • Leaders could not demonstrate that they had the capacity and skills to deliver high quality sustainable care, including the Registered Manager.
  • The practice culture did not effectively support high quality sustainable care due to ineffective significant events and other risk identification and management processes.
  • There was high staff turnover that resulted in staff shortages.
  • There were gaps in staff training and no evidence of inductions for new staff members.
  • There were no clear responsibilities, roles and systems of accountability to support good governance and management.
  • The overall governance and accountability arrangements were ineffective. For example, HR information was incomplete and unclear.
  • The practice did not have clear and effective processes for managing risks, issues and performance. Serious and extensive concerns that were raised by more than a year prior to our inspection had not been resolved.
  • There was no effective process for identification, management and oversight of risk such as provider self-audits to evaluate quality and safety, including no PPG, patient satisfaction surveys or leadership oversight of risks and staff feedback.
  • The provider explained that following the merger the practice population list had grown significantly by approximately 33% and this and the merger had put strain on the practice and prevented them from focus on establishing the new practice. Following our inspection, the practice developed a action plan in July 2023 and updated in December 2023 which demonstrated that the provider was making improvements and responding to our findings.

We found breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation.
  • Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
  • Ensure specified information is available regarding each person employed.
  • Ensure where appropriate, persons employed are registered with the relevant professional body.

Whilst also found the provider should:

  • Improve arrangements to ensure communications made to patients via text message are appropriate.
  • Take steps to check and improve the premises decoration, such as painting.
  • Improve arrangements to ensure patients are aware of the availability of translation services, and sources of support for patients that are carers or are bereaved.
  • Improve arrangements to ensure patients’ privacy in the reception area.
  • Evaluate newly improved arrangements for urgent referrals under the two weeks wait system follow through, to ensure those improvements are sustained.
  • Take action to improve breast, bowel and cervical cancer screening, and uptake of childhood immunisations.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or varying the terms of their registration within six months if they do not improve.

Special measures will give people who use the service the reassurance that the care they get should improve.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care