Lister House Surgery

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.

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 decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access. Care and treatment were delivered fairly and equitably. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.

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 people including those related to protected characteristics under the Equality Act. Our review of clinical records showed people were supported to understand their condition and were involved in planning for their care needs. They were also involved in decisions about their care.

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 service worked in partnership with other services to meet the needs of its patient population. The service had tailored its services to meet the diverse needs of its community.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service’s website could be translated into alternative languages meaning information to promote the take up of screening and immunisation programmes was available in a range of languages.

The service had access to interpreter services, including British Sign Language. Information provided by the service met the Accessible Information Standard.

People were informed as to how to access their care records.

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. People with complex health needs were given longer appointments so they had the time to be listened to.

We saw complaints were managed in line with the service’s policy. Learning from complaints was evident and staff were able to identify changes made as a result of people’s feedback, including complaints.

The service made sure that people could access the care, support and treatment they needed when they needed it. People could access the service to suit their needs either online, in person or by telephone. Treatment rooms were located on the ground floor, with step-free access and automatic doors at the entrance. The service had a cloud-based telephony system with a callback feature to support people accessing the service by phone.

Requests for on-the-day appointments were triaged by clinicians who prioritised those that needed to be seen urgently. We saw appointments were available on the day for urgent cases. There was a 5 week wait for the next available routine appointment. The service told us this was because GPs were taking annual leave over the festive period, and they were in the process of booking locum GPs which would increase availability around that time.

In response to the 2025 National GP Patient Survey data and from feedback from members of the community, the service identified changes to improve access to the service. For example, encouraging people to request appointments online so they don’t have a long wait on the phone. This would also free up the phone lines for those that are digitally excluded.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Feedback provided by people using the service, both to the provider as well as to CQC, was positive. 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, including within the voluntary sector, to address any local health inequalities. For example, a quality improvement project looked at contacting people that considered themselves transgender or gender-neutral to ask them about their patient experience. The project identified some areas for improvement such as staff training to highlight and break down barriers this patient group faced in accessing healthcare. Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes. For example, the dispensary could accommodate people requiring larger font labels or dosette boxes.

The provider had processes to ensure people could register at the service, including those in vulnerable circumstances such as homeless people.

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.

This information was shared with other services when necessary. The records we reviewed showed people were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. However, we reviewed a sample of Treatment Escalation Plan (TEP) forms and found those completed in secondary care were not fully completed to indicate people’s future plans and wishes. The service was aware of this and was in discussions with the Integrated Care Board (ICB) and secondary care about ensuring TEP forms, if appropriate, were fully completed by secondary care to indicate future care plans.