Background to this inspection
Updated
24 April 2019
Lister House Surgery provides a range of primary medical services to the residents of Luton. The
service is provided from the registered location of Lister House Surgery, 473 Dunstable Road, Luton, Bedfordshire, LU4 8DG. Online services can be accessed from the practice website
The regulated activities registered to provide are:
- Diagnostic and screening procedures
- Family planning
- Maternity and midwifery services
- Surgical procedures
- Treatment of disease, disorder or injury
The practice has approximately 7100 patients. The practice population is of mixed ethnicity with an average age range. National data indicates the area is one of mid deprivation.
The practice had three male GP partners although there was not a formal partnership agreement in place and the CQC registration had not been updated. They use three regular GP locums, one male and two females, to support the clinical team. The nursing team consists of a locum advanced nurse practitioner, a nurse practitioner, a practice nurse and a health care assistant, all female. There is a practice manager and deputy practice manager who lead a team of administrative and reception staff. The practice did not have a registered manager in place. A registered manager is an individual registered with CQC to manage the regulated activities provided.
Lister House Surgery is open from 8.30am to 6.30pm Monday to Friday with the telephone lines open from 8am. When the practice is closed out-of-hours services are provided by Herts Urgent Care and can be accessed via the NHS 111 service.
Updated
24 April 2019
This practice is rated as inadequate overall. (Previous rating 06/2018 – Inadequate)
The key questions are rated as:
Are services safe? – Requires improvement
Are services effective? – Inadequate
Are services caring? – Good
Are services responsive? – Requires improvement
Are services well-led? - Inadequate
We carried out an announced comprehensive inspection at Lister House Surgery on 18 and 19 June 2018. The overall rating for the practice was inadequate and the practice was placed into special measures for a period of six months. Warning notices were served in relation to breaches identified under Regulation 12 Safe care and treatment and Regulation 17 Good governance. We completed an announced focussed inspection on 22 August 2018 to check on the areas identified in the warning notices and to see if sufficient improvements had been made regarding these. The practice had taken some of the actions needed to comply with the legal requirements. However, there was still concerns with the leadership and governance of the practice. A further warning notice was served in relation to the breaches identified under Regulation 17 Good governance and a requirement notice was issued for the breaches identified under Regulation 12 Safe care and treatment.
The full comprehensive report on the June 2018 inspection and the focussed report for the August 2018 inspection can be found by selecting the ‘all reports’ link for Lister House Surgery on our website at .
This announced comprehensive inspection on 14 February 2019 was carried out following the period of special measures to ensure improvements had been made and to assess whether the practice could come out of special measures.
We based our judgement of the quality of care at this service on a combination of:
- what we found when we inspected
- information from our ongoing monitoring of data about services and
- information from the provider, patients, the public and other organisations.
We rated the practice as requires improvement for providing safe services because:
- Non-clinical members of staff were sometimes asked to chaperone although they had not all received training for the role.
- Information in the consultation and treatment rooms regarding the treatment of sepsis was not relevant to GP practices.
- We found some irregularities with repeat prescriptions.
- There were no audits or checks in place for the prescribing of controlled drugs or medicines with the potential for misuse.
- A record of blank prescription forms received by the practice was not kept.
- There was no identification on the plug of the vaccine fridge to show it should not be removed.
We rated the practice as inadequate for providing effective services because:
- The practice’s performance on quality indicators for patients with long term conditions was below local and national averages in some areas.
- The practice had not achieved the 90% target for children aged two who had received immunisation for measles, mumps and rubella.
- The practice’s uptake for cervical screening was 61%, which was below the 80% coverage target for the national screening programme.
- Although the practice had developed some measures, there were high exception reporting rates for some quality indicators.
We rated the practice as good for providing caring services because:
- Feedback from patients on the CQC comments cards, the practice’s own survey and the NHS Friends and Family Test was all positive regarding the care received.
- The practice had provided responses and actions for the areas where they scored below the local and national averages in the national GP patient survey published in August 2018.
We rated the practice as requires improvement for providing responsive services because:
- Patients were not always able to access care and treatment in a timely way.
- The 2018 GP patient survey showed the practice scored lower than others locally and nationally for questions regarding appointment booking.
We rated the practice as inadequate for providing well-led services because:
- There remained concerns with the leadership in the practice. There had been four different practice managers in post in the past year.
- There had been changes to the GP partnership but there were no formal agreements in place to support this. Updates to the CQC registration had not been made.
- The GPs and the practice manager had little knowledge of the performance data used and did not proactively take actions to achieve optimum results.
These areas affected all population groups so we rated all population groups as requires improvement, except for working age people and people experiencing poor mental health which were rated as inadequate in effective and therefore rated as inadequate overall.
The areas where the provider must make improvements as they are in breach of regulations are:
- Ensure care and treatment is provided in a safe way to patients.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The areas where the provider should make improvements are:
- Continue to identify and support carers.
- Make improvements to cancer detection and screening rates.
- Continue to improve the uptake of immunisations for measles, mumps and rubella given to children aged two years.
- Continue to look at ways and implement identified actions to improve the levels of patient satisfaction. Particularly in relation to consultations and appointment booking at the practice.
This service was placed in special measures in August 2018. Insufficient improvements have been made such that there remains a rating of inadequate. Therefore, the service will remain in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.
The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.
Special measures will give people who use the service the reassurance that the care they get should improve.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.