City Way Surgery

On this page

• 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 looked for evidence that patients were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had a proactive and positive culture of safety. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Managers encouraged staff to raise concerns when things went wrong. The practice had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave patients support. Learning from incidents and complaints was shared with relevant staff to help prevent recurrence. For example, practice policy and process was amended following a delay in actioning a test result due to staff availability.

Representatives from the Patient Participation Group (PPG) felt the practice took concerns seriously and proactively made improvements to the service.

The practice worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. There were systems in place for processing information relating to new patients. Referrals and test results were managed in a timely way.

The practice had an established and effective system to monitor urgent suspected cancer referrals.

There were effective systems and processes in place to keep people safe. We found alerts on vulnerable children and adults’ records to assist clinicians.

Staff had access to adult and children safeguarding leads in the practice and could also escalate concerns externally if required. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable patients and acted on concerns, working in partnership with other organisations.

Monthly audits were completed to monitor children who had attended Accident Emergency departments, accessed out-of-hours services, or who had not attended scheduled appointments. The practice carried out follow up checks to ensure continuity of care and address any outstanding needs.

The practice worked with patients to understand and manage risks by thinking holistically. They provided care to meet patients’ needs that was safe, supportive and enabled patients to do the things that mattered to them.

Emergency equipment was available. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

In the 2025 national GP patient survey, 81% of respondents reported being involved in decisions about their care, with the national average being 91%.

The practice did not always make sure all equipment supported the delivery of safe care.

We found some emergency equipment had not received routine checks to ensure it was safe to use and had not been identified to ensure safety in the event of a fire. For example, a spare oxygen cylinder located in the reception area. This had not been identified on the practice’s fire plan and there was no signage to alert individuals in the event of a fire. We also identified expired adult and paediatric oxygen masks. We raised this with the practice who immediately provided necessary signage during the inspection. They also updated their emergency equipment checklist to include the spare oxygen tank and removed the expired oxygen masks from its stock.

Contracts were in place to ensure the premises were maintained. For example, fire risk assessments had been completed in November 2024, with the next scheduled for December 2025. Identified risks had been identified and resolved. For example, better record keeping for fire drills, appointing additional fire marshals, updating the floor plans to show refuge points and removal of combustible materials from the electrical room.

Staff had undertaken annual fire safety training, and the practice carried out regular fire drills to help ensure compliance with safety protocols. Staff appointed as fire marshals received appropriate training. We saw fire safety wardens were on duty during our onsite visit.

There were established and effective systems in place to identify, manage and mitigate risks to patients. Health and safety risk assessments and audits had been completed in September 2025. All identified risks were recorded with corresponding action plans, named responsible persons and agreed timescales.

Contracts were also in place to ensure the premises and equipment were maintained. For example, routine legionella testing, portable appliance testing and equipment calibration were routinely conducted by an external company.

There was a business continuity plan in place which was monitored and reviewed.

The practice reviewed the competence of staff working in advanced roles; however, structured clinical supervision was not in place at the time of inspection. Although staff told us they could access support when needed and described an open‑door approach from senior clinicians, we did not see evidence of structured clinical supervision sessions. Following the inspection, the practice told us that it had formalised its arrangements for ongoing clinical supervision to provide a more consistent and structured approach.

The practice made sure there were enough qualified, skilled and experienced staff.

We found mandatory training was up to date, learning needs and development of staff was managed appropriately. Safe recruitment practices were followed.

There were established and effective systems in place to ensure infection prevention and control (IPC) risks were mitigated or removed. The practice conducted an IPC audit in April 2025 which identified areas for improvement, for example repairing worn carpets, redecorating parts of the practice, and reminding staff of the correct guidance for managing sharps bins. We saw an action plan with achievable timescales to address concerns.

We saw that cleaning schedules and Control of Substances Hazardous to Health (COSHH) risk assessments were maintained. Staff had access to gloves, aprons and masks to mitigate the risk of infection to patients. Policies were in place that outlined how staff should triage and manage patients with potentially contagious diseases.

Clinical staff used single use items and had access to body fluid spillage kits to mitigate the risk of infection to patients.

The practice made sure that medicines and treatments were safe and met patients’ needs, capacities and preferences. They involved patients in planning, including when changes happened.

Staff involved patients in reviews of their medicines and helped them understand how to manage their medicines safely.

Our remote clinical searches conducted on 3 December 2025 showed patient reviews were up to date and high-risk medicines were effectively monitored.

The practice had effective systems to manage and respond to Medicine and Healthcare products Regulatory Agency alerts (MHRA - providing alerts, recalls and safety information on medicines and medical devices).

Medicines were stored securely, and staff regularly checked the stock levels and expiry dates for all medicines.

There were systems and processes in place to monitor fridge temperatures to maintain the integrity of stored medicines.

Staff managed prescription stationery appropriately and securely.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data (January 2025 to June 2025) reviewed as part of our assessment confirmed this. For example, the antibiotic prescribing rate for uncomplicated urinary tract infection was in line with national averages.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. In August 2025, an audit was carried out to review the prescribing of Attention Deficit Hyperactivity Disorder (ADHD) medicines for children. This audit identified some patients who had not received a recent medicine review. The practice investigated the reasons for this and implemented an action plan, with the aim to repeat the audit to confirm progress. A follow‑up audit in September 2025 demonstrated improved monitoring of patients prescribed these medicines. A further audit was scheduled for January 2026 to ensure that these improvements were sustained.