We first carried out an announced comprehensive inspection at The New City Medical Group on 13 September 2016. The overall rating for the practice was good; although the practice was rated as requires improvement for providing effective services. We issued a requirement notice with respect to Regulation 18 on staffing because we found that the practice had failed to ensure all staff received appropriate training, to enable them to carry out the duties for which they had been employed.

We carried out an announced focused inspection on 21 November 2017; the practice remained good overall but was rated requires improvement for providing effective services. While there were some improvements, we issued a further requirement notice for Regulation 18 staffing. We found that some staff had not completed training that the provider considered mandatory and the practice did not record or monitor the training completed by the GPs.

The full comprehensive report for these inspections can be found by selecting the ‘all reports’ link for The New City Medical Group on our website at .

This inspection was an announced focused inspection carried out on 7 June 2018 to review in detail the actions taken by the practice to improve the quality of care. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

The practice is rated as requires improvement for providing effective services, and overall the practice is rated as good.

Our key findings at this inspection were as follows:

• The practice had implemented an action plan to address the issues identified at the previous inspection. Improvements had been made, however, a small number of staff had not completed training that the provider considered mandatory.

At our previous inspection on 21 November 2017,

we told the provider that they should make improvements in some areas. We found that the practice did not have a development plan that set out how the provider intended to enact their vision and strategy. We also found that they did not have a planned and structured approach to carrying out clinical audits. At this inspection we found that the practice had not addressed these issues.

• The lack of an effective development plan was first identified when CQC inspected the practice in September 2015, the practice had not taken action to address this area of improvement when we returned in November 2017 or at this inspection. The practice had produced a practice development plan in May 2018. This included a review of the current population needs and workforce. The practice development section of this plan listed several priority areas such as referral management and unscheduled care. However, the plan did not outline how the required work would be done and did not name the people who would be responsible for completing the work. The only priority area which had been identified by the practice and then completed was work to improve patient access to the surgery by the provision of automatic doors. The practice was not able to describe how the plan was linked to the vision and values of the practice.
• The practice did not have a planned or structured approach to carrying out clinical audits. Since we last inspected the practice identified the need for a more structured approach to clinical audit but it did not outline any approach the practice planned to implement.

There was one area of practice where the provider needs to make improvements.

Importantly, the provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care (see the requirement notice at the end of the report for further details).

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The New City Medical Group on 13 September 2016. The overall rating for the practice was good; although the practice was requires improvement for providing effective services. We issued a requirement notice with respect to Regulation 18 on Staffing because we found that the practice had failed to ensure all staff received appropriate training, to enable them to carry out the duties for which they had been employed. The full comprehensive report for the September 2016 inspection can be found by selecting the ‘all reports’ link for The New City Medical Group on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 21 November 2017 to review in detail the actions taken by the practice to improve the quality of care. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

The practice is rated as requires improvement for providing effective services, and overall the practice is rated as good.

Our key findings at this inspection were as follows:

• The practice had implemented an action plan to address the issues identified at the previous inspection.
• However, not all of the required improvements had been made. Some staff had not completed training that the provider considered mandatory and the practice did not record or monitor the training completed by the GPs.

At our previous inspection on 13 September 2016, we told the provider that they should make improvements in other areas. These included recruitment checks, practice development, infection control, clinical meetings and clinical audit. We saw at this inspection that some improvements had been made:

• The provider now completed Disclosure and Barring Service (DBS) checks for all staff appointed at the practice.
• A documented development plan, setting out the actions they would take to deliver their vision and strategy, had not been completed by the practice. Following this inspection the practice sent us an action plan, which showed how they intended to ensure mandatory training was completed and how practice meetings would be more effective. No other areas of practice development were identified.
• A comprehensive infection control audit had been carried out. We saw that the practice had ensured any follow up actions were completed.
• The whole clinical team now attended a clinical meeting each month and these meetings were minuted. However, some of the meeting minutes we reviewed lacked detail that would support the monitoring of any actions required.
• The practice did undertake clinical audit although no two cycle audits had been completed since we last inspected.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• 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 the duties.

In addition the provider should:

• Prepare a development plan that clearly sets out how the GP provider intends to enact their vision and strategy.
• Develop a planned and structured approach to carrying out clinical audits.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the New City Medical Group on 13 September 2016. Overall, the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

• There was an open and transparent approach to safety and an effective system for reporting and recording significant events. The staff team took the opportunity to learn from internal and external incidents.

• Services were tailored to meet the individual needs of patients and were delivered in a way that ensured flexibility, choice and continuity of care.

• Data from the NHS National GP Patient Survey of the practice, published in July 2016, showed patient satisfaction levels with the quality of GP and nurse consultations, and their involvement in decision making, were good.

• Most risks to patients’ safety were effectively managed; however, some risks had not been appropriately assessed, or timely action taken to mitigate identified risks.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

• Clinical staff had the skills, knowledge and experience to deliver effective care and treatment. However, the arrangements for supporting staff to complete all of the training the GP provider considered to be mandatory, were not always effective. For example, insufficient protected learning time had been allocated to ensure all staff were able to complete their mandatory training and, because of this, some staff had not completed all of the training they needed to safely carry out their role.

• The practice worked closely with other organisations, when planning how services were provided, to ensure patients’ needs were met.

• There was a strong, visible, patient-centred culture. Patients said they were treated with compassion, dignity and respect and that they were involved in decisions about their treatment.

• The practice had good facilities and was well equipped to treat patients and meet their needs.

• Clinical leadership encouraged openness and transparency, and promoted a culture where staff felt well supported.

The areas where the provider must make improvements are:

• Persons employed by the provider in the provision of a regulated activity must receive appropriate training as is necessary to enable them to carry out the duties they are employed to perform.

However, there were also areas where the provider needs to make improvements. The provider should:

• Carry out a recorded risk assessment in relation to any decision made not to obtain a Disclosure and Barring Service check for staff appointed to a particular post.

• Prepare a development plan which clearly sets out how the GP provider intends to enact their vision and strategy.

• Carry out an annual comprehensive infection control audit.

• Hold regular clinical meetings, and ensure they are minuted.

• Develop a planned, structured approach to carrying out clinical audits.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The New City Medical Group on 28 February 2019. This was as part of our inspection programme, and to follow up on breaches of regulations.

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.

At the previous comprehensive inspection on 13 September 2016, the practice was rated overall good, but requires improvement for the ‘effective’ key question, with one breach of regulation concerning staff training. This led to a follow up inspection of the effective key question on 21 November 2017. Although some improvements had been made the practice was still found to have a breach concerning staff training, and was still rated requires improvement for the effective key question. A further follow up inspection of the effective key question on 7 June 2018 found the original breach for staff training largely completed, although the practice had a new breach around monitoring activity for clinical audit and staff training, and needed to work on the practice development plan. Therefore the practice remained as requires improvement for effective, although good overall.

At this inspection, we found that the provider had satisfactorily addressed the areas previously rated as requires improvement.

We have rated this practice as good overall, except for providing safe services, which we rated as requires improvement. The practice was rated as good for all population groups except long term conditions, which was rated as requires improvement.

We rated the practice as requires improvement for providing safe services because:

• The provider had failed to ensure the proper and safe management of medicines; specifically those administered under Patient Specific Directions (PSD’s).

We rated the population group of long term conditions as requires improvement because:

• There had been insufficient arrangements for timely recall and review of some long-term conditions patients. Although the practice had identified this, it had caused a delay to some reviews, particularly for housebound patients, and the subsequent catch-up programme was having an effect on nursing availability.

Other findings at this inspection were as follows:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Apart from reviews of long term conditions, patients received effective care and treatment that met their needs.
• Staff involved and treated patients with compassion, kindness, dignity and respect. There was a strong, visible, patient-centred culture, and staff were proud to be able to give multiple examples of helping patients to understand and access timely treatment and support.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The provider was prioritising the development of a clear vision and strategy for how they wanted the practice to develop. They had carefully considered the challenges the practice faced, and were involving staff in the process through planned away days and targeted key areas for improvement.

The areas where the provider must make improvements are:

• Ensure healthcare assistants administer medications only under appropriately completed and monitored Patient Specific Directions (PSD’s).

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• In addition to carrying out a written annual comprehensive infection control audit, document all regular ongoing checks to produce a clear audit trail.
• Record serial numbers of prescriptions as they are taken out of the box for use to create a full audit trail.
• Continue to explore ways to improve the annual review uptake for mental health patients.

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

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice