We carried out an announced inspection at Lister Medical Centre on 6 May 2022. Overall, the practice is rated as Inadequate.
We rated each key question as follows:
Safe - Inadequate
Effective – Inadequate
Caring – Good
Responsive – Inadequate
Well-led – Inadequate
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Lister Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive inspection and the first inspection under the new provider registration.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
- Conducting staff interviews using video conferencing
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- A short site visit.
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 have rated this practice as Inadequate overall
We found that:
- The practice systems and processes to keep people safe were not effective.
- Not all staff were trained to the appropriate level of safeguarding training.
- Some staff did not have appropriate recruitment checks to ensure their suitability for the role.
- A fire risk assessment was overdue.
- Health and safety risk assessments had not been completed when risk had been identified.
- An Infection Prevention and Control (IPC) lead was not in place and staff had not acted on identified significant IPC issues.
- Staff were not equipped to respond to medical emergencies.
- There were not enough staff to provide the number and types of appointments needed and prevent staff from working excessive hours.
- There were delays in the management of referrals and test results.
- Medicines were not stored safely and securely.
- The process for the management of high-risk medicines was not safe.
- Medicines reviews were not always completed.
- The system to receive, review and take appropriate action on Medicines and Healthcare products Regulatory Authority (MHRA) was not effective.
- Learning from incidents was not routinely shared with all staff.
- Patients’ treatment was not always regularly reviewed and updated.
- There were delays in the management of referrals and tasks.
- There were no effective systems for identifying and monitoring vulnerable patients and long-term conditions patients had not been proactively monitored throughout the pandemic;
- Childhood immunisations and cervical cancer screening indicators were below national averages.
- There was no programme of targeted quality improvement in place.
- The practice had failed to use data and information on its clinical record system to drive improvements or monitor care.
- Competency checks had not been completed for all staff.
- The practice did not organise and deliver services to meet patients’ needs.
- Patients were not able to access appointments and treatment in a timely way.
- Complaints were not managed effectively.
- Leaders did not demonstrate they had capacity and skills to deliver high quality sustainable care.
- There was poor governance of the entire service and little or no assurance of processes or systems that were embedded in the organisation.
We found breaches of regulations. The provider must:
- 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.
- Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.
I am placing this service 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 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
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care