Lister House Surgery - Luton

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support.

At our last assessment, we rated this key question as Requires Improvement. At this assessment, the rating has changed to Good.

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 practice made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing, and communication needs with them.

Feedback from people using the practice was positive. Patients told us they felt involved in decisions about their care and treatment and that staff understood their individual needs, including cultural, language and communication requirements. Reception staff were aware of the needs of the local population and used patient record alerts to identify requirements such as interpreter services or longer appointments. The practice also used routine consultations and health reviews to assess patients' health and wellbeing needs and identify those who may benefit from further investigation or support.

The practice had reviewed how patients accessed services and identified opportunities to improve access, including responding to high telephone demand and difficulties some patients experienced when using online services. In response, leaders introduced a Total Triage system to ensure all requests for care were assessed consistently and directed to the most appropriate clinician or service.

Staff used care-navigation and clinical triage processes to help patients receive the right care at the right time. Depending on their needs, patients could be referred to a range of healthcare professionals, including clinical pharmacists, first contact physiotherapists, social prescribers, mental health practitioners, and advanced nurse practitioners. This helped ensure patients received timely and appropriate care while making effective use of the wider multidisciplinary team.

These arrangements enabled the practice to assess and respond to patients' needs effectively and supported the delivery of timely, person-centred care.

The practice planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

The practice had effective systems to ensure care and treatment were delivered in line with current evidence-based guidance and legislation. Staff told us they were supported to keep their knowledge up to date through training, protected learning time, and regular clinical meetings where changes to guidance and best practice were discussed. Clinical records we reviewed demonstrated that care and treatment decisions were consistent with current national guidance.

Patients with long-term conditions received regular reviews to support the ongoing management of their health needs. The practice used a structured recall system based on patients' month of birth to help ensure reviews were completed consistently throughout the year. Follow-up arrangements were in place for patients who did not respond to invitations, and reviews could be completed face to face or remotely, depending on clinical need and patient preference. Patients with multiple long-term conditions could be offered longer appointments to support a more holistic approach to care.

The practice monitored the quality and safety of care through clinical searches, audits, and reviews. Patients prescribed medicines associated with specific risks were managed in line with national safety guidance. Since the last inspection, the practice had strengthened arrangements for patients prescribed SGLT2 inhibitors through improved patient information, documentation and clinical coding.

The practice effectively monitored patients with long-term conditions and those prescribed higher-risk medicines. CQC Clinical searches relating to diabetes, chronic kidney disease and asthma demonstrated generally good standards of care. Where opportunities for improvement were identified, the practice took action, including encouraging reviews following asthma exacerbations and introducing clinical reminders to support ongoing monitoring.

Leaders demonstrated a commitment to delivering evidence-based care. Clinical searches, reviews, and learning events were used to identify areas where care could be strengthened and to support improvements in clinical practice. Following a review of thyroid monitoring arrangements, the practice completed a Learning Event Analysis to review processes and reinforce safe monitoring requirements.

Feedback from a local care home was positive regarding the quality of care provided by the practice. Care home staff told us residents received appropriate assessments, regular reviews, and clear clinical advice. They expressed confidence in the practice's clinical decision-making, prescribing processes and follow-up arrangements and did not raise any concerns about the care provided.

The practice worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support.

The practice worked effectively with internal and external teams to provide coordinated and continuous care for patients. Staff described positive working relationships with GPs, clinical pharmacists, social prescribers, community teams, hospitals, care homes, and Primary Care Network (PCN) colleagues. These arrangements supported joined-up care and helped patients access the most appropriate services in a timely way.

Effective systems were in place to share information between providers. Hospital letters, clinical correspondence, and recommendations from external services were reviewed promptly, and appropriate actions were taken to support ongoing patient care. Relevant information was communicated to clinicians to ensure care and treatment decisions were based on the most up-to-date information.

The practice worked closely with local care homes to support residents' health and wellbeing. Regular GP visits, medication reviews, monitoring, and follow-up care were coordinated with care home staff and the wider multidisciplinary team. This helped promote continuity of care and ensure residents received timely and appropriate support.

Staff worked collaboratively to ensure patients were directed to the most appropriate clinician or service for their needs. This multidisciplinary approach supported effective care planning, medicines optimisation, long-term condition management, and ongoing patient support. Where appropriate, patients were referred or signposted to other healthcare professionals and services to ensure their needs were met.

The practice actively engaged with the wider PCN and other healthcare providers. Learning, guidance, and service updates from external meetings were shared through practice meetings and internal communications, helping to ensure staff remained informed and changes were implemented consistently across the service.

The practice supported people to manage their health and wellbeing to maximise their independence, choice, and control. The practice supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The practice took a proactive approach to promoting health and preventing illness. Patients were encouraged to participate in national screening programmes, immunisation campaigns, NHS Health Checks, and other preventative health initiatives. Recall systems were used to identify and invite eligible patients for cervical screening, vaccinations, long-term condition reviews, and other health checks.

The practice used a range of methods to encourage engagement with preventative healthcare, including text message reminders, telephone calls, discussions during consultations and health promotion information displayed within the practice and shared electronically. Patients who did not respond to invitations were followed up where appropriate to encourage attendance and identify any barriers to accessing care.

Staff supported patients to make positive lifestyle changes and improve their overall wellbeing. Patients could access social prescribing services for support with issues such as physical activity, weight management, and social isolation. The practice also referred eligible patients to diabetes prevention programmes and worked with the wider Primary Care Network team, including clinical pharmacists, to support people with long-term conditions. Additional wellbeing initiatives, including community walking groups, were available to promote healthier lifestyles.

Health promotion information and advice were readily available, and staff routinely signposted patients to services such as smoking cessation support, weight management programmes, and diabetes management services.

Screening and immunisation performance was mixed. Cervical screening uptake for women aged 50 to 64 years was 80.2%, meeting the national target. Uptake for women aged 25 to 49 years was lower at 60.3%. Childhood immunisation uptake also varied.

Staff took a proactive approach to supporting patients at increased risk of poorer health outcomes. For example, patients with long-term conditions were actively recalled for reviews and monitoring, while patients identified as being at risk of developing diabetes were referred to prevention and lifestyle support programmes. Patients requiring wider support were signposted to social prescribing services and community organisations to help address social, emotional and practical factors affecting their wellbeing.

Leaders were aware of these challenges and had implemented targeted recall and engagement activities to improve uptake. They recognised that local demographics and cultural factors could influence participation in screening and immunisation programmes. Staff told us they worked proactively with patients through education, culturally sensitive discussions, and personalised support to address concerns, promote informed decision-making and reduce health inequalities.

The practice routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

From the clinical notes we reviewed, we found that people who used the practice experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. The practice used clinical audits, targeted searches, medication reviews, and governance processes to monitor patient outcomes and identify areas where care could be improved. Clinical searches were used to review patients with long-term conditions and those prescribed higher-risk medicines, enabling timely intervention, monitoring and follow-up where required.

The management of long-term conditions was regularly reviewed against national guidance. Clinical reviews relating to diabetes, asthma, chronic kidney disease, and hypothyroidism demonstrated that most patients were receiving appropriate monitoring and treatment. No significant concerns were identified in relation to diabetes or chronic kidney disease management. Where opportunities for improvement were identified, the practice took prompt action to strengthen patient care.

The practice demonstrated a commitment to continuous improvement through the use of audits and quality improvement activity. Following a review of asthma management, systems were strengthened to encourage routine follow-up after asthma exacerbations through patient recalls, patient messaging, and clinician reminders. The practice used audit findings to monitor performance, evaluate the effectiveness of changes, and support improved patient outcomes.

The practice also introduced a deprescribing and inactive repeat medication policy to support safe prescribing and improve the accuracy of medication records.

Systems were in place to identify and support patients who may be at increased risk of poorer health outcomes. Targeted recall systems were used to invite patients for long-term condition reviews, screening programmes, vaccinations and medication monitoring. Where patients did not respond, staff took additional steps to encourage engagement and understand any barriers to accessing care, helping to ensure support was tailored to individual needs.

The practice supported people to make informed decisions about their care and treatment and obtained consent in line with legislation and guidance.

Staff demonstrated a good understanding of consent, the Mental Capacity Act 2005 and their responsibilities when supporting patients to make decisions about their care and treatment. Relevant staff had completed appropriate training and were able to describe how they assessed and recorded mental capacity when required. There were systems and processes in place to obtain and record consent in line with legislation and guidance, and clinicians told us they routinely sought consent before providing care and treatment.

The practice supported people to make informed decisions and involved family members, carers or advocates where appropriate. Information about patients' rights regarding consent was available, and people were informed that a chaperone was available if needed through information displayed within the practice and on the practice website. Feedback from patients and care home representatives indicated that people felt informed, involved and supported when making decisions about their care.

Records reviewed showed that patients were involved in decisions about their care wherever possible. Where patients had capacity, discussions and decisions were made directly with them. Where patients lacked capacity to make specific decisions, records demonstrated appropriate involvement of relatives, next of kin, advocates and other representatives, ensuring decisions were made in the person's best interests and reflected their wishes wherever possible.