document: Care Quality Commission (CQC) inspectors rated almost every aspect of care at Sunderland's Hylton Medical Group as "inadequate".
  The group, which operates two sites for 5,240 patients, came out of its first spell in special measures a year ago.
  Clinical commissioners described the rating as "disappointing".
  Alison Holbourn, deputy chief inspector of general practice at the CQC, said: "We found that people were not getting the high quality of care which everyone should expect to receive from their GP.
  "Following improvements at a previous inspection in April last year, the practice has been unable to sustain these and they now return to special measures.
  "We remain particularly concerned about the effectiveness of the service the practice provides to patients."
  Ms Holbourn added: "There were no audits taking place, so staff had no way of knowing if the services provided to patients were improving their outcomes.
  "Following this inspection we also found fresh concerns around leadership. We weren't confident the practice was providing effective clinical leadership or that leaders had a comprehensive understanding of the practice performance.
  "I do not believe that the practice is likely to resolve its challenges without external support.
  "Where necessary, another inspection will be conducted within six months and if there is not enough improvement we will move to close the service and remove the provider's registration."
  David Gallagher, chief officer at Sunderland Clinical Commissioning Group, said: "It is disappointing the practice has received this rating, but we continue to work with NHS England and other partners to help the practice team tackle the issues that have been raised and make the necessary improvements.
  "Patients at the practice can continue to use the service in the usual way, and we would encourage anyone who is concerned about the report to contact the practice."
summary: A GP practice has been warned it could be closed down after inspectors placed it in special measures for a second time.