City Square Medical Group

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• 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 found the practice had made improvements following the previous inspection in May to July 2023. For example, the leaders had implemented new systems, practices, and processes to keep people safe. The practice has 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. Leaders had improved the environment. However, although the leaders were trying to recruit more staff, staff told us there were not enough staff to meet patient needs at the practice. In addition, prior to the assessment the leaders had not identified a number of outstanding tasks in the patient record system, once identified they immediately responded.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The national GP patient survey carried out from January to March 2023 had 115 responses. This found 82% of patients stated the healthcare professional was good at listening to them, and 82% of patients stated they were involved as much as they wanted to be in decisions about their care and treatment. In addition, 88% of patients had confidence and trust in the health care professional they saw or spoke to. CQC did not speak to patients on the days of the assessment. Eighteen complaints were received by CQC from July 2023 to February 2024, 4 were regarding staff attitude. At the time of the assessment the practice had not carried out their own patient survey.

Leaders and staff told us they knew how to identify and report concerns, safety incidents and near misses both internally and externally. They were able to discuss evidence of some learning and dissemination of information. Leaders described a system for recording and acting on patient safety alerts. Staff told us that complaints were responded to promptly, discussed at governance meetings and lessons were learnt. The practice had carried out a well led staff review in May 2024, where 11 staff responded. Most staff responded that when reported, they felt that mistakes and significant events were investigated well, and they were made aware of the learning points and outcomes.

The practice had a system in place to manage safety alerts, which was supported by a Central Alerting System Policy last reviewed in June 2023. As part of our assessment, several sets of clinical record searches were undertaken by a CQC GP specialist adviser. These searches were visible to the practice. We reviewed five patient records who may have been affected by a Medicines and Healthcare products Regulatory Agency alert, and we found all had been informed of the side effects of the medicines. The practice had significant event and incident and complaints policies last reviewed in February 2024. We saw that the practice had a system in place to report, investigate and learn from significant events and complaints. Significant events were standard agenda items at partners and practice meetings, and where learning was discussed. We reviewed two complaints and two significant events which demonstrated the systems at the time of the assessment were effective. The practice had a duty of candour policy in place which was last reviewed in February 2024, and we saw that it was considered as part of the complaints and significant events processes.

The national GP patient survey carried out from January to March 2023 had 115 responses. This found 75% of patients stated the healthcare professional was good at treating the patient with care and concern, and 82% of patients stated they were involved as much as they wanted to be in decisions about their care and treatment. In addition, 87% stated their needs were met. When asked about accessing the practice, 51% stated the experience of making an appointment was very or fairly good. CQC have received 18 complaints from July 2023 to February 2024, 2 were regarding pathways and 6 were regarding access to the practice. CQC did not speak to patients on the days of the assessment.

Leaders and staff told us there was a system to ensure referrals to specialist services were documented, and contained the required information. There was a system to monitor urgent referrals and any delays, which was the responsibility of a designated partner. The process followed the patient through their entire hospital pathway until either diagnosis or discharge so that no diagnosis was missed. The system was reviewed as a standing item in the quality and safety committee for oversight purposes to ensure that it was fit for purpose and achieving its aim. Staff told us there was a documented approach to the management of test results and these were reviewed in a timely manner and there was appropriate clinical oversight of the results, including when reviewed by non-clinical staff. Leaders explained they had a dedicated member of staff to process information relating to new patients including the summarising of new patient notes. Also, they had shared care agreements in place for patients who were treated by secondary care. We reviewed a sample of shared care agreements and found no concerns. During the assessment CQC found 1100 tasks in the patient record system which had not been completed, the leaders immediately responded to this and reviewed the tasks to ensure patient safety and improved the protocol for managing tasks at the practice.

The leaders explained they had a multidisciplinary team meeting monthly to discuss and improve outcomes for people with complex needs and a monthly meeting with the health visitors to discuss child safeguarding. The practice supported one care home for older people, the manager confirmed that staff attended the home weekly, responded promptly to their requests, and they had good lines of communication with the practice. The leaders explained they were working within their local primary care network to develop a triage hub service to capture patients who contacted the NHS 111 service and provide triage so that they can be provided with the correct GP appointment.

The practice had embedded a system into the patient records to monitor the uptake of referrals, this included a safety netting template which enabled the practice to carry out a weekly review of urgent referrals. The leaders submitted a 2 week wait referral protocol reviewed in January 2024 and a Fastrack referral and safety netting investigation search protocol reviewed in April 2024. However, although this explained the system it did not cover the reasoning for the urgent appointments, we also noted that the practice had 3 significant events which involved patient referrals, within the last 12 months. A review of a sample of five patient records regarding their referrals found no concerns. The practice had a pathology links flow chart in place to instruct staff how to manage test results, this was reviewed in January 2024. A review of the pathology results demonstrated they were dealt with promptly. A review of tasks within the patient clinical system found 1022 tasks which had not been completed and some were regarding patients and marked for escalation. In response to the CQC assessment findings, the leaders carried out an audit of the tasks and improved the protocol for task management at the practice. We reviewed a sample of shared care agreements and found no concerns.

We could not collect the evidence to score this evidence category.

The practice had a safeguarding GP lead and deputy who were allocated time to review patients where there were safeguarding concerns. Leaders told us the practice had developed a platform, which was reviewed monthly, was accessible to all staff, and enabled them to input into the monthly safeguarding meetings with the other agencies. Vulnerable adults were called monthly by the care coordinators, and any concerns from this were escalated in meetings. Partners explained they and staff were trained to appropriate levels for their role. We reviewed two sets of minutes of safeguarding meetings and found both did not include the outcome or follow up of the patients. The practice also monitored children who were not brought to appointments. Non-clinical staff were aware of who to report any safeguarding concerns to.

The children’s safeguarding leads met monthly with the health visiting team and reviewed any children at risk. In addition, vulnerable adults were included in the monthly meeting with the integrated care board.

The practice had systems, practices, and processes to keep, people safe and safeguarded from abuse. A review of patient records found the practice had a system to highlight vulnerable adults and children to staff. The leaders submitted safeguarding children and vulnerable adults’ policies last reviewed in April 2024, which provided information for staff to follow to enable the safe response to a safeguarding concern. All but one member of staff had completed the appropriate safeguarding training, 14 out of 18 staff had completed prevent radicalisation training.

The national GP patient survey carried out from January to March 2023 had 115 responses. This found 88% of patients had confidence and trust in the health care professional they saw or spoke to. However, only 48.5% patients responded positively to how easy it was to get through to someone at their GP practice. CQC received 18 complaints from July 2023 to February 2024, there were no specific complaints regarding safe and supportive care but 6 were regarding access to appointments. CQC did not speak to patients on the days of the assessment.

The practice was based over two sites, and leaders told us there was an effective approach to managing staff absences and busy periods. However, staff told us there were not enough reception staff to meet patient demands. The leaders explained that they were recruiting to new posts, a duty doctor was available to provide support to reception staff and a doctor was available at both sites whilst the practice was open. Also, the administration managers were located at both sites. Receptionists told us the actions they would take if they encountered a deteriorating or acutely unwell patient and described how they would allocate patients to the different clinicians. The leaders explained that any online consultations went into a separate mailbox and were dealt within 48 hours.

We observed the practice sites were equipped to respond to medical emergencies, including suspected sepsis, and all equipment was regularly checked. The practice had protocols in place to manage the prioritisation of patients. Staff had completed basic life support, anaphylaxis, and sepsis training. The practice had a locum induction pack for agency staff to follow.

The provider told us that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste. Staff explained any maintenance concerns were now promptly responded to by the leaders and improvements had been made. The leaders explained that fire wardens were available at each site.

We visited Cable and Deancross Street branches, and we observed that improvements had been made following the previous inspection. We saw risk assessments were in place for fire safety, legionella and health and safety and actions had been taken.

The practice had completed fire risk assessments, fire drills and emergency lighting checks for both sites and most actions had been marked as completed. The practice provided evidence of annual portable appliance testing, and calibration of equipment for all sites. Fourteen out of 18 staff members had completed their fire safety training and the principles of health and safety training. Four staff members had completed fire warden training.

The national GP patient survey carried out from January to March 2023 had 115 responses. This found 88% of patients had confidence and trust in the health care professional they saw or spoke and 75% stated the health care professional was good at treating the patient with care and concern. In addition, 87% stated that their needs were met. However, 65% found the receptionists helpful which was below the 82% of the national average. CQC received 18 complaints from July 2023 to February 2024, 4 were regarding the staff’s attitude. CQC did not speak to patients on the days of the assessment.

The leaders told us they had a system in place to review training and competency of allied and clinical staff every three months. The leaders explained staff had three monthly supervisions, which included consultation reviews and completed annual appraisals. The leaders told us that staff now always worked within their job description and competency. At the time of the assessment, the practice had recruited a practice nurse and had one pharmacist who completed long-term condition health checks only. The leaders told us they had sufficient clinical staff and met their NHS target to provide 110 appointments each week per 1,000 patients and they were aware of the need for more administration staff and were recruiting. The practice had carried out a well led staff review in May 2024, which surveyed the 11 staff. Fifty-three percent of staff stated the practice had enough qualified, skilled and experienced people.

The practice had a recruitment policy, last reviewed in January 2024; this included the necessary recruitment checks. We reviewed five staff files and found all the necessary checks had been completed. The leaders submitted a clinical supervision overview of which member of the leadership team supervised staff and a clinical supervision and continuing profession development policy which was last reviewed in January 2024. In addition, they submitted a list of supervision meetings. We found most staff had completed the mandatory training for their role. However, the practice used an online system to monitor supervision, and training, and we found further work was required to ensure the staff had full oversight of the training and supervision. At the time of the assessment the provider had one independent prescriber, who saw patients with long term conditions. We found they had an agreed scope of practice in place, a job description, quarterly patient consultation records reviews and supervision.

We could not collect the evidence to score this evidence category.

The leaders explained the practice nurse was the lead for infection prevention and control, and they carried out regular infection prevention and controls checks of all the premises. In addition, staff carried out a daily check.

We visited both sites and found appropriate standards of cleanliness and hygiene were being met.

Staff had completed an infection prevention and control audit for each site in January 2024 and had a system in place to ensure that the rooms were checked daily. The practice had acted on any issues identified in infection prevention and control audits. The practice had completed legionella risk assessments for both sites and had caried out remedial action. Sixteen out of 18 staff had completed infection prevention and control training.

We could not collect the evidence to score this evidence category.

The leaders explained there was a process for monitoring patients’ health in relation to the use of medicines including high-risk medicines (for example, warfarin, methotrexate and lithium) with appropriate monitoring and clinical review prior to prescribing. Staff told us they had a system in place to ensure the safe prescribing of patient’s repeat medicines. Staff explained the systems they used to monitor vaccines, emergency equipment and medicines. At the time of the assessment, leaders said the practice had one independent prescriber.

We saw staff ensured medicines were stored safely and securely with access restricted to authorised staff. Staff had the appropriate authorisations to administer medicines (including Patient Group Directions or Patient Specific Directions). There was a process for the safe handling of requests for repeat medicines and evidence of effective medicines reviews for patients on repeat medicines. Blank prescriptions were kept securely. The practice held appropriate emergency medicines, risk assessments were in place to determine the range of medicines held, and a system was in place to monitor stock levels and expiry dates. There was medical oxygen and a defibrillator at each site and systems to ensure these were regularly checked and fit for use, which staff had access to. Vaccines were appropriately stored, monitored and transported in line with UKHSA guidance to ensure they remained safe and effective.

The practice had a system in place to monitor the fridge and clinical room temperatures for the safe storage of medicine, this was supported by a policy which was last reviewed in January 2025. The practice had put systems in place to monitor the safe administration of patients’ medicines, the prescribing of repeat medicines and the monitoring of emergency medicines. The provider did not stock-controlled drugs. The provider monitored the prescribing of the independent prescriber.

As part of our inspection a number of set clinical record searches were undertaken by a CQC GP specialist adviser. These searches were visible to the practice. We found that monitoring was appropriate overall. The clinical searches found patients receiving the high-risk medicine methotrexate were put on repeat prescriptions, recalled for tests as required by guidance, and the GP was responsible for checking the necessary tests were conducted prior to prescribing. The clinical searches identified 1002 patients taking a high-risk medicine for high blood pressure and heart failure. We sampled 5 of 9 patients identified as possibly not having the correct monitoring and found only one patient was overdue their monitoring and the practice had continued to provide 2 monthly prescriptions. The clinical searches reviewed patients over 70 years prescribed non-steroidal anti-inflammatory drugs (NSAID), anticoagulants and antiplatelets (medicines for pain, inflammation, fever, and prevent blood clots). Out of 110 the search identified 7 who had no prevention medicine, we sampled 5 patients and found no concerns. We found the practice had completed 777 annual medicine reviews in the last three months. We reviewed a sample of 5 and found no concerns. Unverified practice data demonstrated the practice had completed 92% of patients’ medicines reviews from 1 April 2023 to 31 March 2024. The NHS Business Services Authority medicines data in January to December 2023, which reviews hypnotic, multiple psychotropics and antibacterial prescribing results were either in line or better than the national average.