Lister House Surgery - Luton

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.

This service scored 72 (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 a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The practice had effective systems and processes to identify, investigate and learn from incidents, significant events, complaints and audit findings. Staff understood their responsibilities for reporting concerns and told us they felt supported by leaders to raise issues when needed. They described an open and positive culture where learning was encouraged and patient safety was prioritised.

Incidents and significant events were reported and investigated in line with established procedures. Reviews identified contributory factors, learning and actions required to reduce the risk of recurrence. Learning was shared through team meetings, meeting minutes, email communications and electronic resources to ensure staff remained informed and able to apply improvements in practice.

There were clear arrangements for managing complaints and concerns. Staff aimed to resolve issues promptly where possible, with more complex matters investigated through formal procedures. There was evidence that duty of candour principles were understood and applied appropriately. Patients received explanations, apologies and support when things had not gone as expected.

We identified the practice used information from incidents, complaints, significant events and audits to improve services and strengthen governance processes. Staff provided examples of improvements made following learning, including changes to information governance processes and enhanced patient education relating to medicines. Where learning needs were identified, additional training and support were provided to help staff develop their knowledge and skills.

The practice worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The practice had effective systems and processes to ensure referrals, test results, investigations and follow-up care were managed safely and acted upon in a timely way. Clinical and administrative staff used electronic systems to monitor patient care, ensuring that results were reviewed, referrals were tracked and any necessary actions were completed. GPs maintained oversight of clinical results, while administrative staff carried out checks to ensure patients were contacted and follow-up arrangements were in place where required. The practice also completed medicines reconciliation and reviewed previous medical records for newly registered patients to support the continuity and safety of care.

Staff worked within clearly defined roles and responsibilities and were appropriately trained to carry out their duties. Administrative staff demonstrated a good understanding of clinical coding, correspondence management and prescription processes, and knew when to seek support from clinicians. Systems were in place to ensure patients received appropriate monitoring and medication reviews, and referral processes, including urgent referrals, were monitored to reduce delays in care and treatment.

The practice used clinical audit and performance monitoring to support the quality and safety of care. Areas reviewed included medicines management, prescribing safety, long-term condition monitoring and sepsis assessments. Where improvements were identified, the practice took appropriate action, such as recalling patients for review, strengthening monitoring arrangements, updating prescribing processes and providing additional staff training. Repeat audits were used to assess the effectiveness of these actions.

The practice had effective arrangements to identify and manage risks. Business continuity plans were in place to support the safe delivery of services during unexpected disruption, including loss of premises, clinical systems, utilities or staffing shortages.

The practice had introduced a structured Total Triage system to support safe and consistent access to care. All requests for appointments and advice were assessed through the same process, regardless of whether patients contacted the practice online, by telephone or in person. Administrative staff had received care navigation training and worked under clinical oversight to ensure patients were directed to the most appropriate clinician or service. Standardised triage processes and quality assurance checks helped promote consistency and patient safety.

Feedback from a local care home provided additional assurance regarding the effectiveness of the practice's systems and processes. Staff described the practice as responsive, reliable and supportive. They told us communication was effective; GP visits took place as planned and residents received appropriate reviews and follow-up care. Care home staff expressed confidence in the practice's clinical decision-making and prescribing processes and did not raise any concerns about the care provided. This demonstrated effective partnership working and supported the delivery of safe, coordinated care for care home residents.

The practice worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The practice shared concerns quickly and appropriately.

The practice had effective safeguarding systems and processes to protect vulnerable patients. Staff demonstrated a good understanding of their safeguarding responsibilities and were confident in identifying, reporting and escalating concerns appropriately. Clear safeguarding pathways were in place, with concerns raised to the Duty Doctor and Safeguarding Lead for review and action. Staff told us they felt supported to seek advice when needed and understood the importance of responding promptly to safeguarding concerns.

There were named safeguarding leads who provided oversight and support to staff. Relevant staff had completed safeguarding training appropriate to their roles and were familiar with the systems used to identify and monitor vulnerable patients. Safeguarding alerts and coding were used within patient records to support information sharing, risk monitoring and continuity of care.

Safeguarding was embedded within day-to-day practice. Vulnerable patients and safeguarding concerns were discussed during regular multidisciplinary team huddles, enabling staff to share information, review risks and agree appropriate actions. Records showed that concerns were reviewed, actions were documented and follow-up was undertaken where required. The practice also worked closely with external agencies, including social care and other healthcare providers, to ensure patients received appropriate support and protection.

The practice took a proactive approach to safeguarding through safer recruitment processes, Disclosure and Barring Service (DBS) checks, safeguarding training, whistleblowing arrangements and regular review of safeguarding concerns. Systems were in place to ensure safeguarding referrals, communications from partner agencies and case outcomes were appropriately recorded. The practice also had processes to follow up vulnerable patients who did not attend appointments, including hospital appointments, helping to reduce the risk of people falling through gaps in care.

Overall, the practice had effective safeguarding arrangements. Staff understood their responsibilities, safeguarding concerns were managed appropriately, and there was evidence of effective multidisciplinary and multi-agency working to promote people's safety and wellbeing.

The practice worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The practice supported patients to be involved in decisions about their care and encouraged them to raise concerns about their health when needed. Patients were assessed according to the urgency of their needs, with same-day appointments available for those requiring urgent clinical assessment. Staff understood how to identify signs of deterioration and ensured concerns were escalated promptly to a GP or Duty Doctor. Where appropriate, patients were directed to urgent care services or advised to seek emergency treatment.

The practice had systems in place to support the ongoing monitoring of patients with long-term conditions and those at greater risk of poor health outcomes. Patients were invited for reviews, monitoring, and follow-up appointments to help ensure risks were identified and managed appropriately.

The practice had effective arrangements in place to respond to medical emergencies. Following a risk assessment, emergency medicines and equipment were relocated to a single designated location to improve accessibility and support rapid response times. Staff were familiar with emergency procedures and described undertaking regular checks and drills to ensure equipment was available and ready for use. Leaders explained that these changes were introduced following staff feedback to ensure emergency equipment could be accessed quickly during time-critical situations.

The practice detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed.

There were effective arrangements to manage risks relating to health and safety, premises, and service continuity. A range of risk assessments had been completed, including those relating to clinical room use, stock storage and IT system failures. Risks were appropriately assessed and actions taken to reduce or manage them. The practice also had a business continuity plan in place to support the continued delivery of services during periods of disruption.

Staff told us they had access to the equipment and resources needed to carry out their roles safely and effectively. They had completed relevant health and safety training, including fire safety training. During the inspection, we observed that fire exits were unobstructed and fire safety equipment was in place and subject to regular servicing and checks.

Leaders had appropriate arrangements to protect the confidentiality, integrity, and security of patient information. Staff had completed information governance training and demonstrated a good understanding of how to manage confidential information securely.

The practice demonstrated a proactive approach to risk management and continuous improvement. During the assessment, following a review of emergency medicines and equipment, leaders identified that the location of emergency medicines could be improved to support timely access in an emergency. A risk assessment was completed and emergency medicines were subsequently relocated alongside the emergency trolley. The practice also strengthened its governance arrangements by introducing regular documented checks of emergency equipment and medicines to provide ongoing assurance that these were readily available and fit for use when required. The practice also identified opportunities to improve accessibility for patients for example enhanced disabled parking signage was introduced to improve visibility and support patients with mobility needs. Information displayed within the waiting area was reviewed and updated to ensure it was clear, accurate and accessible.

Leaders used risk assessments to inform decision-making and responded promptly to issues identified, helping to maintain a safe, accessible, and well-managed environment for patients and staff.

The practice made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision, and development. They worked together well to provide safe care that met people’s individual needs.

Feedback from patients and care home representatives was positive about the knowledge, skills, and professionalism of practice staff.

The practice employed a range of clinical and non-clinical staff. Staff completed mandatory training relevant to their roles, and systems were in place to monitor compliance, identify learning needs and support ongoing professional development. Staff told us they felt supported and had access to supervision, appraisals, and performance reviews.

The practice ensured staff worked within their level of competence and had appropriate support to carry out their responsibilities safely. All new staff completed a role-specific induction, and clinical staff had access to advice and guidance from GPs when required. A duty GP was available to provide clinical support and discuss patient management, including home visits and follow-up care.

Safe recruitment procedures were followed. Recruitment records showed that appropriate pre-employment checks, including Disclosure and Barring Service (DBS) checks where required, had been completed. The professional registration of clinical staff was verified at recruitment and monitored on an ongoing basis.

The practice had effective arrangements for chaperoning. Chaperone duties were undertaken by appropriately trained staff, and clear guidance was available to support the role.

Staff undertaking specialist clinical activities, including long-term condition reviews, childhood immunisations and cervical screening, had completed appropriate training and competency assessments. Clinical staff working in extended roles, including prescribing responsibilities, received ongoing supervision, peer support and regular clinical oversight.

Leaders monitored staffing levels and workforce capacity to help ensure continuity of care. Arrangements were in place to provide clinical and administrative cover during periods of planned and unplanned absence. Some staff were trained to undertake additional responsibilities, which helped maintain services and supported patients to receive safe and timely care.

Overall, the practice had effective systems to ensure staff were appropriately recruited, trained, supported, and supervised to deliver safe and effective care.

The practice assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

The practice had effective arrangements in place to prevent and control infection. A designated Infection Prevention and Control (IPC) Lead Nurse, who had completed additional IPC training, provided oversight of IPC arrangements and supported staff in maintaining good practice. Staff were aware of the IPC lead and understood their responsibilities for preventing and controlling infection within the practice.

All staff completed IPC training appropriate to their role as part of their induction and ongoing training programme. Staff demonstrated a good understanding of IPC procedures, including the safe handling of clinical specimens and the management of bodily fluid spillages. They knew where spill kits were located and understood the actions required in the event of an infection control incident. Occupational health arrangements were also in place, including the review of immunisation status and vaccination requirements for staff.

Regular IPC audits were carried out to monitor compliance and identify opportunities for improvement. These included routine infection control checks and more comprehensive audits covering equipment decontamination, environmental cleanliness, and cleaning standards. Audit findings were reviewed, shared with staff, and used to support continuous improvement. We reviewed a sample of actions arising from audits and found these had been completed appropriately.

There were effective systems to maintain a clean and safe environment. During the inspection, the premises were visibly clean and well maintained. Documented cleaning checks were completed, and clear arrangements were in place to communicate and address any issues with the cleaning contractor. Infection prevention and control arrangements were also integrated with wider health and safety processes to support the identification and management of environmental risks.

The practice demonstrated effective antimicrobial stewardship. Data showed that antibiotic prescribing was lower than expected when compared with similar practices, indicating antibiotics were prescribed appropriately and in line with national guidance.

Leaders also took prompt action to strengthen infection prevention and control arrangements. A sink plug identified as a potential infection control risk was removed, and plans were developed to install an additional handwashing sink to improve access to appropriate hand hygiene facilities. Security arrangements were enhanced through improved signage for the cleaning cupboard, with plans to introduce restricted access controls.

Regular monitoring, staff training, and effective leadership supported a proactive approach to infection prevention and continuous improvement.

The practice generally made sure that medicines and treatments were safe and met people's needs, capacities and preferences. They involved people in planning, including when changes happened. The practice had systems and processes in place to support the safe management of medicines. Feedback from patients and care home representatives was positive, with people expressing confidence in how their medicines were prescribed, reviewed and monitored. Patients were involved in decisions about their treatment and were provided with information to support the safe use of medicines and help them understand when to seek further advice.

Medicines were generally stored securely and managed appropriately. This included vaccines, medicines requiring refrigeration, emergency medicines and controlled drugs. Regular checks were undertaken to monitor stock levels, expiry dates and storage temperatures. Prescription stationery was managed securely, and Patient Group Directions (PGDs) were in place to support the administration of vaccines by nursing staff. During the assessment, the practice identified opportunities to strengthen oversight of PGD authorisation records and subsequently implemented additional controls and a formal policy to ensure a more consistent approach.

Staff had received training appropriate to their roles and were able to describe their responsibilities in relation to prescribing, medicines management and monitoring. Systems were in place to support the monitoring of patients prescribed higher-risk medicines, and clinical searches undertaken during the assessment provided assurance that appropriate action was generally being taken. The practice also had effective medicines reconciliation processes to support the safe management of medicines following hospital attendance or specialist review. Arrangements were in place to manage medicines safety alerts and recalls, with affected patients identified and followed up where necessary through clinical system searches and prompts.

Leaders regularly reviewed prescribing data, undertook clinical searches and completed audits to identify risks and drive improvement. Evidence showed the practice responded appropriately when risks were identified. For example, prescribing arrangements for some asthma medicines had been strengthened, monitoring and follow-up processes for patients prescribed osteoporosis medicines had been improved, and prescribing processes for high-risk medicines had been reviewed. Where required, repeat prescribing arrangements were amended and medicines were deprescribed when treatment was no longer appropriate or could not be monitored safely.

The practice used clinical audit to support medicines optimisation and prescribing safety. Audits had reviewed areas including antibiotic prescribing, anticoagulant use and higher-risk medicines. Learning from these reviews was shared with clinicians and used to improve prescribing practices, monitoring arrangements and documentation. Prescribing data showed the practice prescribed fewer antibiotics than local and national averages, demonstrating a positive approach to antimicrobial stewardship.

However, the practice had identified a backlog of routine medication reviews, meaning some reviews had not been completed within expected timescales. Leaders recognised the potential risk and had implemented a structured recovery plan, including additional clinical capacity and prioritisation of patients according to clinical need. Although action had been taken to address the issue, the backlog indicated that oversight of routine medicines reviews had not always been fully effective.

Overall, the practice had many of the systems needed to support safe medicines management and demonstrated a willingness to identify and address risks through audit, monitoring and clinical review. While improvements had been made in response to identified concerns, further work was required to ensure medication reviews were completed consistently and that medicines governance arrangements were fully embedded and operating effectively.