Lister House 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 people were protected from abuse and avoidable harm.

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.

The service had a good learning culture and staff felt confident with raising concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment were suitable for people’s needs, kept clean, well-maintained and any risks effectively managed. There were enough staff with the right skills, qualifications and experience. Managers ensured staff received ongoing training and regular appraisals to maintain high standards of care. Medicines were managed safely, and people were involved in planning any changes.

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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff felt supported to raise concerns and told us they were treated with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Leaders encouraged staff to raise concerns when things went wrong. The service closed for half a day a month to hold a whole team where learning from clinical issues was discussed. Staff felt there was an open culture, and that safety was a top priority.

The provider 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 people support. Learning from incidents and complaints resulted in changes that improved care for others.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new records. We found there were 211 records waiting to be summarised, the oldest record waiting was from January 2024. The service was aware of this backlog and had a plan to clear it within the next 4 months. These records had been reviewed when they arrived and given a colour relating to how urgent they were to be summarised and processed. Any record rated as high-risk were prioritised.

The service worked with other providers to deliver shared care and when people moved between services. Referrals and test results were managed in a timely way.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. Safeguarding was a standing item on the agenda at regular meetings. The service regularly reviewed a list of vulnerable people and acted on concerns working in partnership with other organisations. The service had access to a local platform where information and concerns were shared and contact details of healthcare professionals involved with people can be viewed.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Systems and processes assessed, monitored and managed risks to people’s safety. People were informed of any risk relating to their care and staff documented this in people’s records. As part of our inspection, a number of set clinical record searches were undertaken remotely by a CQC GP specialist advisor. These searches were visible to the service. Our clinical searches identified a total of 20 people prescribed teratogenic medicines (a medicine that can negatively impact a foetus during pregnancy). We reviewed 5 of these records and found all had been managed in line with guidance.

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

The service had policies and processes in place to detect and control potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed.

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

Step-free access and ground levels rooms support people with accessibility needs.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the service. We found training was up-to-date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Staff had received an annual appraisal.

Safe recruitment systems and processes were followed and where information was missing from staff files, a risk assessment had been completed.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. Sharps bins and clinical waste were managed appropriately.

There was a process to record staff vaccinations in line with national guidance. Where evidence was missing, a risk assessment had been completed.

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

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely.

Medicines including controlled drugs were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, vaccines, and controlled drugs. We found 3 vials of expired emergency medicine and some confusion around what should and shouldn’t be stocked. The service told us there had been a recent change in the list of stocked medicines which had resulted in a discrepancy. The service took immediate action to investigate and address this.

Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. The service reviewed a scorecard on a monthly basis to ensure they had oversight of ensuring people were being monitored effectively.

There were suitable processes for staff to follow when dispensing medicines. The dispensary lead kept systems and processes for the dispensary under review. Access to the dispensary was restricted to ensure medicines were managed safely. Staff in the dispensary were able to raise queries directly with GPs. Controlled drug keys were stored in a secure key safe with CCTV monitoring and sign-in/out logs, while fridge temperatures were regularly monitored. The dispensary team carried out mandatory annual audits in line with guidance. Emergency stock ordering was handled upon request.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of Co-amoxiclav, Cephalosporins or Quinolones antimicrobials issued by the provider observed to be 3.2% which was lower than the expected 7.9%.

We reviewed a sample of Patient Group Directions (PGDs) (a written instruction for the supply and/or administration of a named licensed medicine for a defined clinical condition by named registered health care professionals without them having to see a prescriber) and Patient Specific Directions (a written instruction from a doctor or other independent prescriber for a medicine to be supplied or administered to a named patient) and found they had been completed correctly in line with guidance).