City Square Medical Group

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We found the practice had made improvements following the previous inspection in May to July 2023. For example, leaders changed the governance at the practice and introduced safety and quality and partner meetings, which had implemented and reviewed the improvement plan, monitored performance and managed risk. Leaders had worked with staff to develop a shared direction and culture.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders stated they had a new vision, values and strategy for the practice which they had developed with staff. They had undertaken a staff listening exercise and appointed a wellbeing lead and developed a plan and a staff charter which included focusing on developing a positive, compassionate, listening and celebrating-diversity culture. Although prior to the assessment we had received negative comments from staff, during the assessment staff told us that there had been improvements and leaders were now approachable and listened. Staff told us there was coordination and working between the branches and managers were mostly available at both sites. The practice had carried out a well led staff review in May 2024, which surveyed the 11 staff members. This found all staff had a sense of the practice’s vision, values, and strategy, felt positive and proud to work at the practice and felt they demonstrated how much they respected and valued everyone in the practice.

Following our previous inspection the practice had put in place an action plan and a quality and safety group. They and the partners group had reviewed the plan monthly. Staff had been allocated roles and had job descriptions in place. The leaders had developed a staff charter which described what staff could expect from the leaders and what was expected of them. Staff were now offered supervision and a supervision algorithm was in place to inform staff of who their supervisors were. The practice had developed a mission statement which was to work collaboratively with patients and other healthcare professionals to provide a high level of patient centred care that we would expect for ourselves or a family member and to ensure patients are always treated with dignity, honesty, and respect and to work closely with the local community.

In response to the findings of the previous inspection, the leaders explained they had developed new committees and refreshed the senior management team structure to provide senior partners with dedicated management time. This led to increased visibility of the senior management team at the locations. The leaders explained they had improved their recruitment process to ensure staff with new values, strategy and had included actions to respond to poor behaviours. The leaders explained the practice offered flexibility in the hours staff worked to enable staff to meet their cultural and caring responsibilities. The practice had carried out a well led staff review in May 2024, which surveyed the 11 staff members. This found all staff stated they felt positive and proud to work at the practice, most of the staff stated the leaders consulted staff when making changes that affected the practice, and half stated they were recognised and thanked for the work they did by the leadership team.

The practice had put in place job descriptions for all staff and had ensured staff were aware of their roles and responsibilities. A review of a sample of staff files found the practice was following an improved recruitment process. The action plan, performance monitoring and new committees demonstrated the leaders now understood the challenges to quality and sustainability and had identified the actions necessary to address the necessary challenges.

Staff told us they now felt the leaders were approachable and felt comfortable to speak up. There were greater levels of staff involvement including dedicated slots on practice meetings to raise issues and prompt review of concerns raised. Staff were able to speak up anonymously through paper and online forms. Staff we spoke with told us they felt able to make their concerns known to the leaders. The practice had carried out a well led staff review in May 2024, which surveyed the 11 staff. This found most staff felt that mistakes and significant events were investigated well.

The staff charter included that the leaders provided an environment free from discrimination and harassment, where staff members contribution was valued, and they were protected from abuse. The practice had a whistle blowing policy and procedure last reviewed in January 2024, this included details of the freedom to speak up guardian.

The practice had developed the role of well being lead to improve staff morale. The leaders explained that they provided flexible working arrangements and time for staff to follow their religious and cultural beliefs. Staff had access to wellness, stress and financial advice. The leaders had held an away day to bring staff together to meet and understand each other’s roles, which they hoped would improve communication at the practice. The practice had carried out a well led staff review in May 2024, which surveyed 11 staff, who stated how much they respected and valued everyone in the practice.

The staff charter included that the leaders provided an environment free from discrimination and harassment, where staffs contribution was valued, and they were protected from abuse. Most staff had completed equality and diversity training and learning disability awareness.

In response to the previous inspection the leaders had developed a new governance structure that provided oversight by the senior management team. The action plans, risk register and performance were reviewed at monthly quality and safety and partner meetings, this included significant events, complaints, training and supervision, recruitment, long-term conditions and medicine reviews, staff leavers and patient feedback. New systems were in place to ensure that staff worked within their roles and competencies. The leadership team were aware they required further staff and were recruiting a practice and reception manager, administration staff and a salaried GP. The practice had carried out a well led staff review in May 2024, which surveyed the 11 staff and found all felt positive about working at the practice, however, only half felt they planned well at the practice.

In response to the findings of the previous inspection, the practice had reviewed their systems and processes and made improvements to provide better governance, quality assurance and risk management. This included significant events, recruitment, supervision and appraisal, and the management of long-term condition. The practice had developed an organisational development plan, a risk register, assurance dashboard and an action plan which were discussed at the quality and safety group and partner meetings monthly. The practice had a Business Continuity Plan & Policy which was reviewed in May 2024. The practice had completed a data security and protection toolkit valid until June 2024. However, the provider had not identified the number of outstanding tasks on the patient record system prior to the assessment, and the oversight of staff training was unclear. The leaders responded immediately to these issues during the assessment.

The staff had held a patient participation group meeting in March 2024 and planned to hold every three months, the group had four members. We spoke with a member of the group who stated the practice had listened to their concerns and made changes and they felt that the practice was improving.

Leaders told us they collaborated with stakeholders and had active Integrated care meetings engaging with district nursing, care agencies, mental health, care navigators and palliative care. In addition, they had regular meetings with health visiting. The practice also had a psychiatrist and a mental health worker who saw patients in the practice. The staff attended virtual mental health meetings to discuss mental health patients with the mental health team. The practice was working within their primary care network to deliver specific projects for diabetes.

The leaders explained they had a multidisciplinary team monthly meetings 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 residential care home for older people, the manager confirmed that staff attended the homes 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 various projects and provided the example of a same hub arrangement 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 worked closely with local practices to develop a pathway to educate patients from calling NHS 111 or going to the urgent care treatment centres rather than their GP. Learning from deaths was a standing item on the Integrated care meetings to allow cross partner learning. Patient deaths were also reviewed at practice meetings.

The leaders explained there was a process of continuous learning, improvement and innovation in the practice. Data was reviewed at the quality and safety group, partner manager meetings and practice meetings and actions agreed. They explained that audit was to form a key part of practice learning as it led to change. Complaints and significant events were reviewed, and learning shared within the practice and externally. Examples of learning were the update to the urgent referral and long-term health conditions recall process.

The practices most recent clinical meeting had carried out a comprehensive review of the last six months patient deaths to ensure that religious and cultural needs were met. The practice worked with other agencies to improve patients’ health. For example, patients’ awareness of symptoms, to enable earlier treatments, specific diabetes clinics, triage of NHS 111 patient calls.