Archived: Dr Aamer Khan Also known as The Lister 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

Staff told us that leaders and managers were visible and approachable and that they felt supported by them. The practice understood its duty to collaborate and work in partnership with other services, to support communities. Staff told us they were provided with adequate training for their roles and supported with their professional development. There was a positive learning and improvement culture which helped to drive improvements in safety and outcomes for patients.

This key question has been rated as Good.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had developed a shared vision, strategy and culture. The practice told us its vision was ‘to be recognised as a high-achieving, inclusive, and responsive practice that delivers outstanding healthcare to every patient, every time’.

The practice had recently developed a brief business plan which included some plans for services over the next 5 years. This included plans to source further clinic space within the building.

Staff told us that leaders and managers were visible and approachable and that they felt supported by them.

Leaders told us that they encouraged a culture of openness and that they had had an open-door policy which allowed staff to approach them directly; this was corroborated by feedback we received from staff.

Staff told us they had been supported to undertake training and development, and that they had the opportunity to attend external courses and regular meetings where information was shared with them.

Staff we spoke with and received feedback from told us they knew how to raise concerns and felt confident to do so. There was a whistleblowing policy and freedom to speak up guardian in place. Staff reported an open culture where they were encouraged to share ideas and concerns.We saw examples of candour being applied by staff where errors had occurred, followed by implementing of actions to prevent recurrence.

There were systems and processes in place to support the safety of staff. This included policies on lone working and zero tolerance. Equality and diversity training was part of the mandatory training requirements for staff.There was also a reasonable adjustments policy in place for staff, and we heard examples of how staff had been supported to carry out their role, for example by being able to work flexibly when this had been requested.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Staff told us they had access to policies and procedures to support them within their role.

Leaders told us about the ways in which they monitored and mitigated risks and performance. For example, they were continuously working to improve their childhood immunisation and cervical screening uptake rates. The practice also had a risk register, and we were told that this was reviewed on a quarterly basis.

The practice had processes in place to submit data to external organisations. However, we found that the practice had formed a Partnership in 2020 and had failed to appropriately make changes to its registration with the Care Quality Commission (CQC), despite guidance from CQC prior to the Partnership formation, on how a potential change in legal entity should be handled. This had also not been identified by the practice as part of its governance processes. After the assessment the practice had taken steps to rectify this.

There was a meeting structure in place and minutes available to staff who could not attend. Staff attended regular meetings where issues complaints, significant events and clinical concerns were discussed. There was a business continuity plan and this detailed arrangements in place in the event of certain incidents.

Staff used data to monitor and improve performance. For example, GPs regularly reviewed prescribing and referral rates.

There was a data security protection policy in place and information governance training was provided to staff. Staff we spoke with were aware of the importance of patient confidentiality and information security.

Workflows for communication and pathology results were up to date at the time of our assessment. There was however a significant backlog of patient records to be summarised, with the practice manager being the only trained summariser at the time of the assessment. The practice told us it had plans in place to train more staff in this process.

There were processes in place to maintain safe and effective staffing at the practice, however clinical supervision for non-medical prescribers was not documented and did not include audits of their prescribing. The practice told us it would immediately change its processes to ensure regular and formal clinical supervision was in place for these staff going forward.

Managers met with staff regularly to complete appraisals and performance reviews.

The practice understood their duty to collaborate and work in partnership, so services worked efficiently for patients. They told us about the ways in which they worked with their primary care network and supported communities, for example by hosting regular cancer awareness events and by running vaccination sessions at local community centres and places of worship.

The practise gathered patient feedback from the National GP Patient Survey, Friends and Family Test (FFT), complaints and compliments. We reviewed the responses to the FFT from March to June 2025 and found that each month there were over 300 respondents, at least 94% of which rated their overall experience of the practice as good or very good.

Staff told us they were provided with adequate training for their roles and some staff gave examples of how they were supported with their professional development.

The practice had a programme of quality improvement activities which included clinical and non-clinical audits, and learning from significant events and complaints. The practice had also recently taken part in the National General Practice Improvement Programme, in order to drive improvement within the practice.

The practice collaborated with other services to try and deliver better outcomes for patients. This included working with an organisation to try and improve the management of patients with type 2 Diabetes.