- GP practice
City Way Surgery
Report from 19 November 2025 assessment
Contents
Ratings
Our view of the service
Date of Assessment: 3 December 2025 to 9 December 2025. City Way Surgery is a GP practice and delivers service to approximately 13,000 under a contract held with NHS England. The National General Practice Profiles states that the ethnic make-up of the practice area is 79% White, 10% Asian, 6% Black, 3% Mixed and 2% Other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 5th decile (5 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report. The purpose of the assessment was to follow up on the breach of regulation identified at the previous inspection and to review information of concern that had been received.
Since the last inspection on 18 April 2023, the practice had made improvements. Previously we found improvements to care and treatment were required regarding some patient reviews; the practice was unable to demonstrate its processes and systems were effective in managing risks related to security concerns and the handling of incoming test results. While some actions were ongoing in response to the national GP patient survey results (2022), the practice was unable to demonstrate the impact of the measures that had been implemented. We found that most of these previously identified issues had been resolved. The practice was carrying out further work in response to the most recent GP patient survey results.
Some patients experienced difficulties accessing appointments and reported receiving inconsistent information when trying to book. However, we saw, patients were involved in decisions about their care and felt able to give feedback, with confidence that the service listened and acted on it. People were supported to plan their care and understood their options, including choosing to withdraw or not receive care.
The practice had a learning culture and people could raise concerns. Managers investigated incidents. People were protected and kept safe. The premises were clean, well-maintained and risks were mitigated. Staff managed medicines well and involved people in planning changes. However, some safety processes required strengthening. These included checks of emergency equipment to ensure all items were in date, ensuring all oxygen cylinders were included in monitoring records, and establishing structured clinical supervision sessions.
Patients were involved in assessments of their needs. Staff reviewed assessments taking account of patient’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in patient’s care for the best outcomes and smooth transitions when moving services. Staff made sure patients understood their care and treatment to enable them to give informed consent. When a patient did not have capacity, staff appropriately involved people important to them when making decisions in the patient’s best interests.
Patients were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. Patients had choice in their care and treatment. The practice supported staff wellbeing.
Leaders were described by staff as visible, approachable and supportive, and most felt confident raising concerns. Some staff noted occasional tensions between partners, though they said leaders were generally willing to listen and adapt. Governance systems required strengthening, including oversight of emergency equipment checks, clinical task oversight, and structured clinical supervision.
We identified a breach of regulation in relation to good governance due to gaps in monitoring emergency equipment, oversight of the clinical task system, and the absence of structured clinical supervision sessions. We have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
The national GP patient survey (2025) received 96 responses, representing a completion rate of 26%. The findings showed 35% of respondents responded positively to how easy it was to contact the practice on the phone. This was below the national average of 52%. This was reflected in the feedback CQC received in the 12 months prior to the assessment. Further, 61% of respondents responded positively to the overall experience of their GP practice. This was below the national average of 75%.
The 2025 national GP patient survey revealed that 73% of respondents felt they were treated with care and concern, slightly below the national average of 85%. Further, 86% reported having confidence and trust in the clinician they had consulted with, with the national average being 92%. In addition, 75% reported the clinician they had seen at their last appointment was good at listening to them, with the national average at 86%.
Feedback gathered through the NHS Friends and Family Test indicated majority satisfaction rates between August and November 2025.
There was an active patient participation group (PPG) who represented the views of people using the service. Representatives from the PPG described a positive relationship with the practice and highlighted that some changes had been made in response to their feedback.