City Square Medical Group

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination.

At our last inspection in 2023, we rated this key question as Requires Improvement because patients complaints and feedback was not acted upon. At this assessment, we found that this had changed. The practice is therefore now rated as Good for providing a responsive service.

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.

The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Care plans reflected physical, mental, emotional, and social needs of patients including those related to protected characteristics under the Equality Act. Our review of clinical records showed patients were supported to understand their condition and were involved in planning for their care needs. They were also involved in decisions about their care.

A focused engagement programme was implemented to improve uptake of mental health care plans. This included targeted patient outreach and structured follow-up processes. As a result, completion rates increased from 88.1% to 95% over a 12-month period.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

We saw the practice worked in partnership with other services to meet the needs of its patient population. The practice demonstrated a strong understanding of its patient demographic and tailored its services to meet the diverse needs of its community. This included building relationships with 17 local community groups to address social, cultural and language barriers, and to promote the uptake of screening programmes. There were established mechanisms for engaging with community healthcare providers.

For example, the practice supported a “Creative English through role play and drama” project, aimed at women from South Asian backgrounds with limited English. This initiative helped build confidence in social and work settings, reduced isolation, and encouraged community engagement. Activities such as coffee mornings and group sessions promoted peer support and trust, while monthly trips supported mental wellbeing.

The service supplied appropriate, accurate and up-to-date information in formats tailored to individual needs. Information to promote the uptake of screening and immunisation programmes was available in a range of languages. The practice had access to interpreter services, including British Sign Language, and information provided met the Accessible Information Standard. Patients were informed about how to access their care records. The practice had also introduced a new initiative of quarterly newsletters, with three produced in the last quarter, covering health education, service updates and self-care.

The practice had implemented a visual impairment accessibility project. Patients identified as visually impaired were proactively contacted and personalised reasonable adjustments, such as larger font sizes (for examples Font 25+), were recorded on their clinical notes. All identified patients (10) had appropriate adjustments added, achieving 100% compliance.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result. Results from the 2025 National GP Patient Survey reflected positive patient experiences in relation to communication and involvement in care. For example, 81% of respondents stated that the last healthcare professional they saw or spoke to was good at listening to them during their most recent general practice appointment, and 86% reported they were involved as much as they wanted to be in decisions about their care and treatment.

We saw complaints were managed in line with the practice’s policy. Learning from complaints was evident, and staff were able to identify changes made as a result of patient feedback, including complaints. Complaints were a standing agenda item at team meetings, where learning was shared with all staff to support continuous improvement. The practice also had an active Patient Participation Group (PPG), which provided a forum for patients to share feedback and contribute to service development. All staff we spoke with were able to clearly describe the complaints process.

The service made sure that people could access the care, support and treatment they needed when they needed it. The provider had implemented a range of systems and tailored pathways to improve equitable access for patients, particularly for those at risk of exclusion, disability, mental ill health, social isolation or digital disadvantage. The practice maintained a reasonable adjustments list to identify and support patients with additional needs when accessing services. Patients identified as vulnerable, including palliative care patients, care home residents and vulnerable adults, could access a priority telephone line which enabled them to bypass the main call queue and access support more quickly.

The practice reviewed patient feedback and national survey data to help improve access to services. The 2025 National GP Patient Survey received responses from 129 patients. Of these, 36% reported that they found it easy to get through to the practice by telephone, which was below the national average of 53%. In addition, 34% of respondents said they were offered a choice of time or day when they last tried to make a general practice appointment, which was also below the national average of 54%. Following the changes implemented by the practice to improve patient satisfaction, an internal patient survey was conducted. This demonstrated that, of the 124 respondents, 51% reported that they found it easy to get through to the practice by telephone.

The practice implemented a total triage model and had systems to support patients who were digitally excluded. Reception staff assisted patients to complete online triage requests either by telephone or in person, and alerts were placed on patient records to ensure staff were aware when additional support was required. Paper registration forms remained available for patients unable to access online systems. The provider also had a named NHS App Champion who supported patients to download and use the NHS App, alongside participation in “Doctor Digital” sessions delivered at Primary Care Network level to improve digital confidence amongst patients.

In addition, the provider had developed bespoke access pathways for vulnerable groups including patients with learning disabilities, patients with mental health needs, residents living in supported housing and patients requiring British Sign Language (BSL) support. For example, the practice identified through audit activity that some patients living in supported housing who were supported by community mental health teams were not attending appointments. In response, the practice implemented a dedicated access pathway and worked collaboratively with housing staff and carers to support appointment booking and attendance. Patients with learning disabilities were offered enhanced appointment reminders, longer appointments and tailored support to improve engagement with healthcare services.

Telephone access data reviewed by inspectors demonstrated improvements in access arrangements between 2023 and 2026. The proportion of missed calls from the queue reduced from 21.2% in January 2023 and 21.5% in February 2023 to 16.0% in January 2026 and 16.1% in February 2026. Average queue waiting times for answered calls also improved from 8 minutes 3 seconds in January 2023 and 7 minutes 27 seconds in February 2023 to 4 minutes 42 seconds in January 2026 and 4 minutes 56 seconds in February 2026. The number of queued calls also reduced significantly during this period, from 5,130 calls in January 2023 and 4,554 calls in February 2023 to 2,930 calls in January 2026 and 2,619 calls in February 2026, indicating improved demand management and call handling processes. The provider had additionally introduced appointment check and cancellation options, and a submission help function to support patients accessing the total triage system.

The provider had considered the needs of patients with sensory or physical impairments. A hearing loop was available within the practice and interpreters could be arranged in up to 30 languages, including British Sign Language interpreters. The patient arrival screen and practice website included language options to support accessibility. The practice also undertook a quality improvement project focused on improving accessibility for patients who were blind or partially sighted by ensuring written communications were provided in accessible formats.

The practice environment had also been adapted to support equitable access. A quiet room was available for patients who may become overwhelmed in busy waiting areas, including patients with autism or other disabilities, and could also be used for breastfeeding or prayer. Patients and carers who preferred not to wait in the waiting area could wait outside and be contacted by telephone when the clinician was ready to see them.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience and outcomes and tailored their care, support and treatment in response to this. The provider demonstrated a proactive approach to identifying patients who may be socially isolated, vulnerable or at risk of poorer health outcomes. For example, the practice carried out searches to identify patients aged over 65 who had not engaged with a GP, nurse or pharmacist within the previous 12 months. Patients identified through this process were contacted by care coordinators to assess whether they were socially isolated, required additional support or should be added to the vulnerable adult register.

The provider had developed a vulnerable adults list comprising approximately 120 patients who received proactive monthly welfare calls from care coordinators. During these contacts, staff assessed wellbeing, medication needs, social isolation and access barriers. Concerns identified during these reviews were escalated to the duty GP or Integrated Care Lead to ensure timely intervention and continuity of care. Staff told us this proactive approach had been introduced following learning that some vulnerable patients were not engaging with services unless proactive contact was made.

Additionally, the practice used audits and service reviews to identify inequalities in patient engagement and adapt services accordingly. For example, the provider identified that patients with learning disabilities were more likely to miss appointments and subsequently introduced enhanced reminders, longer appointments and tailored support to improve attendance and engagement.

This was supported by findings from the 2025 National GP Patient Survey. Results showed that 87% of respondents felt their needs were met at their last appointment, and 91% reported they knew what the next steps were within two days of contacting the practice.

Feedback provided by people using the service, both to the provider as well as to CQC, was positive. Four patients had also shared positive feedback about their experience of the practice through the “Tell us about your care“ feature on the CQC website. Staff treated people equally and without discrimination. Leaders proactively sought ways to address any barriers to improving people’s experience and worked with local organisations, to address any local health inequalities. Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes. The provider had processes to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people and Travellers. Staff used appropriate systems to capture and review feedback from people using the service, including those who did not speak English or have access to the internet.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life. Our review of a sample of care plans showed that people were supported to consider and document their wishes for end-of-life care, including decisions relating to cardiopulmonary resuscitation. This information was shared with other services when necessary to support coordinated care.

Feedback from the 2025 National GP Patient Survey also indicated that patients felt supported in managing their health and ongoing conditions. For example, 53% of respondents stated they had received enough support from local services or organisations in the previous 12 months to help them manage their long-term conditions or illnesses, which was comparable to the local average of 61%.

Patients also had access to a social prescriber through the practice. This professional supported them by helping them access community services and non-clinical support, such as groups, activities or practical assistance, which could improve wellbeing and help people better manage the wider social factors affecting their health.