Lister House Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

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.

Leaders and staff shared a clear vision and culture and fostered a culture built on openness, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. A culture of continuous improvement was evident, with staff given dedicated time to explore and implement new approaches.

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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

All staff had contributed to the development of the service’s vision and strategy, which was kept under review. The service was aware of the projected increase in the local population and was working with partner agencies to address future challenges and demands on the service.

There was an open-door policy where staff felt confident to speak up and felt they would be listened to. Staff were supported to identify learning and development opportunities to further their professional development and benefit the patient population.

Staff spoke positively about the daily huddle meetings where changes were communicated and issues such as safeguarding concerns could be raised.

The service had inclusive leaders at all levels who demonstrated a clear understanding of the context in which care, treatment and support was delivered. They embodied the values and culture of the workforce and organisation. Leaders had the necessary skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders were approachable and responsive to any concern. Leaders demonstrated the organisation’s values in their actions. The leadership team worked with other services in the primary care network and under the same provider to engage in the development of primary care services within the local area.

The service promoted an open and positive culture where staff felt confident to raise concerns and trusted their voice would be heard. Staff had access to policies and procedures and were aware of how to raise concerns.

Freedom to Speak Up arrangements were established both internally and external, and staff felt assured their concerns would be taken seriously.

The service demonstrated a commitment to workforce diversity and actively promoted an inclusive and equitable culture. Policies and procedures to promote diversity and equality were established. Staff were able to explain their understanding of equality, diversity and inclusion and had completed training.

Adjustments had been made to ensure all staff were valued. Staff gave examples of reasonable adjustments the service had made to support them both at work and in personal circumstances.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Governance bulletins were sent to all staff to ensure they were kept up-to-date of any changes.

Leaders held daily huddles and regular meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff.

Staff took confidentiality and information security seriously.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The provider worked with other services within their primary care network to offer extended access. Staff had improved coordination of their service with community healthcare services. For example, the palliative care lead recently implemented a monthly meeting and where possible, the local hospice attended to ensure a joined-up approach to care for these people.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encourage creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The service had a clear plan for quality improvement to ensure continuous development.

in place to help drive improvements in services. For example, a recent project had reviewed safeguarding processes, identified areas for improvement or change and the service had taken action to make improvements.

All staff were encouraged to carry out audits and present their learning at full team meetings.