Lister House Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

This is the first inspection for this service since its registration with CQC. We assessed all the quality statements in the safe key question. This key question has been rated as good.

People were involved in assessments of their needs. Staff carried out reviews that took into account peoples’ individual communication, personal and health needs. Care was delivered in line with the latest evidence and best practice. Staff worked with all relevant services involved in peoples’ care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people took decisions in people’s best interests where they did not have capacity to make their own decisions.

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’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. All staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments for people with complex needs. Staff checked people’s health, care, and wellbeing needs during health reviews.

Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had effective systems to identify people with previously undiagnosed conditions. For example, our clinical searches identified 5 people with a potentially missed diagnosis of diabetes. We reviewed all 5 records and found 4 people had been managed and coded appropriately. The fifth person had very recently had a blood test result that indicated they may be diabetic and the service was in the process of taking the next steps.

Staff were able to refer people with social needs, such as those experiencing social isolation or housing difficulties, to an external agency who could signpost them to services in the community.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Systems were in place to ensure staff were up-to-date with evidence-based guidance and legislation. Our review of clinical records demonstrated care was being provided in line with current guidance.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The service worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. Staff told us teams worked well together and provided positive feedback about working at the service.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff focussed on identifying risks to peoples’ health, including those in the last 12 months of their lives, people at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity. People could self-refer or be referred to external agencies, who linked them to local non-clinical services in the community designed to enhance their health and wellbeing.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves. The service met national targets for childhood immunisations according to the latest data available for the period April 2023 to March 2024. Verified data for cervical screening available at the time of this assessment was from June 2024 and showed the service was not meeting the national uptake target of 80%. However, unverified data shared by the service showed they had met the 80% target uptake of cervical screening as of November 2025.

Our review of clinical notes confirmed people who used the service achieved positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. Staff followed policies and processes to support people to consent to care and treatment. Staff understood and applied legislation relating to consent. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were recorded in people’s records using Treatment Escalation Plan (TEP) templates provided by the local Integrated Care Board (ICB). We viewed a sample of these forms and found those completed by the service’s staff contained appropriate information. However, TEP forms completed in secondary care were not thoroughly filled in and did not contain information about capacity and consent. The service was aware of this and was in discussions with the ICB and secondary care about ensuring TEP forms, if appropriate, were fullycompleted by secondary care to indicate consent or that capacity to make a decision was considered.