Lister House Surgery - Luton

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• 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

We looked for evidence that the practice leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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

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 had a clear set of values focused on safety, quality, compassion, integrity and continuous improvement. Staff understood the needs of the local population and demonstrated a commitment to delivering patient-centred care. Leaders regularly reviewed service demand, patient feedback and performance information to ensure services continued to meet the needs of the community.

The practice demonstrated a proactive approach to service development. For example, an additional consultation room had recently been created to increase clinical capacity and improve access for patients. A risk assessment was completed to ensure the room was only used for patients who could safely access the first floor, demonstrating consideration of patient safety and accessibility.

Staff consistently described the culture as supportive, inclusive and team focused. They told us they felt valued, respected and able to raise concerns or suggest improvements without fear of criticism. Staff reported that leaders were approachable, visible and responsive, and that communication across the practice was open and effective.

Regular team meetings, clinical huddles and protected learning sessions provided opportunities for staff to share information, discuss challenges and contribute to improvement. Staff told us they were encouraged to participate in decision-making and felt their views were listened to.

Evidence demonstrated a positive and inclusive culture, with leaders and staff sharing a common focus on delivering safe, effective and compassionate care.

The practice had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Practice leaders were visible, approachable and demonstrated the skills and experience needed to manage the service effectively. Staff spoke positively about leaders and told us they felt supported, respected and able to raise concerns or suggest improvements.

Leaders promoted open communication and collaborative working through regular meetings and learning events. Staff told us they felt listened to and were encouraged to contribute to service development.

Staff described a fair and respectful working environment where people were treated equally and supported to develop professionally. As a training practice, leaders supported learning and development through supervision, mentoring and access to training opportunities for both clinical and non-clinical staff.

Leaders demonstrated a commitment to continuous improvement and responded appropriately to feedback, patient needs and service pressures.

The practice fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had established Freedom to Speak Up arrangements.

Some staff were not fully aware of the designated internal Freedom to Speak Up contact. However, staff told us they felt comfortable raising concerns directly with practice leaders and described the practice as having a strong open-door culture. Staff said they would not hesitate to speak with the Practice Manager or other leaders if they had concerns and felt confident that issues would be listened to and acted upon.

Following feedback, the practice had taken steps to strengthen staff awareness and understanding of the Freedom to Speak Up process. Leaders demonstrated a commitment to promoting an open and honest culture where staff could raise concerns safely and without fear of detriment.

The practice had developed a Freedom to Speak Up Staff Information and Declaration Form, which outlined the process for raising concerns, available support routes, and the roles of both internal and external Freedom to Speak Up contacts. The document reinforced the practice's open-door policy and commitment to treating concerns fairly, respectfully and confidentially.

Leaders had implemented a range of measures to increase awareness, including discussing the Freedom to Speak Up process at practice meetings, sharing contact details for the internal wellbeing champion and external Freedom to Speak Up Guardian, and making this information readily accessible to staff. All existing staff would be required to read and sign the declaration form, and the process had been incorporated into the induction programme for new staff. Leaders also told us that awareness would be refreshed annually.

These actions demonstrated the practice's commitment to further strengthening an already open culture, ensuring staff understood the different routes available for speaking up and felt supported to raise concerns relating to patient safety, quality of care and workplace issues.

The practice valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and procedures to promote equality, diversity and inclusion were in place.

We saw senior leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support staff who had a disability were in place. Staff told us they felt valued, supported and included, regardless of their role within the organisation.

The practice had policies and procedures in place to support equality, diversity and inclusion across the workforce. These were supported by recruitment, induction, mandatory training and staff development processes.

There was a supportive and approachable leadership style, and staff described a culture where their wellbeing was considered. The practice's open-door approach helped to encourage open communication and foster positive working relationships throughout the team.

The practice was committed to supporting workforce development and creating opportunities for career progression. Staff had access to training and professional development opportunities appropriate to their roles. Workforce planning included arrangements for recruitment, retention, succession planning and leadership development to help ensure the sustainability of the service.

The practice also demonstrated a commitment to supporting the future primary care workforce.

The practice had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The practice demonstrated effective governance, management and sustainability arrangements. Leaders used governance systems to oversee the quality and safety of services, manage risks and support continuous improvement. There was evidence that information relating to performance, patient outcomes, risk and service delivery was routinely reviewed and used to inform decision-making.

A comprehensive governance framework supported effective oversight of the service. Leaders met regularly through daily clinical huddles, operational meetings, GP partner meetings and multidisciplinary forums. These meetings provided opportunities to discuss patient safety, review risks, monitor performance, share learning and coordinate care for patients with complex needs.

The practice had made a number of improvements since the previous assessment. Leaders had introduced a Total Triage system and Duty Doctor model to improve access and ensure patients were directed to the most appropriate clinician. Clinical pathways for long-term conditions, including diabetes and hypertension, had been strengthened, alongside oversight of prescribing, referrals and clinical supervision. Feedback from staff and patients indicated these changes had supported improvements in service delivery and access to care.

Quality improvement was embedded within the organisation. The practice maintained a programme of clinical audits and service reviews covering areas such as prescribing safety, medicines optimisation, antimicrobial stewardship and long-term condition management. Audit findings were used to identify opportunities for improvement and monitor the impact of changes made. For example, a two-cycle audit of mirabegron prescribing demonstrated improvements following intervention and review.

Following a review of Patient Group Direction (PGD) authorisation records, leaders completed a risk assessment and introduced a dedicated PGD Authorisation Record Policy. This provided clearer arrangements for document control, staff authorisation, auditing and version management. Similarly, a review of emergency medicines and equipment resulted in improvements to storage arrangements, staff awareness and ongoing monitoring processes.

Leaders demonstrated a commitment to workforce sustainability and development. As a training practice, the service supported trainee GPs and provided opportunities for learning, peer support and multidisciplinary working. Daily clinical huddles facilitated shared learning and discussion of clinical and operational matters.

Leaders displayed an understanding of future risks and service demands. Workforce planning, succession arrangements and business continuity plans were in place to support the ongoing delivery of services during periods of increased demand or unexpected disruption.

Leaders reviewed audit findings, prescribing data, safety information, and improvement actions through regular clinical and governance meetings. Information from audits, clinical searches and safety alerts was used to identify trends, monitor performance and support improvements in patient care.

Overall, governance systems were effective and supported the delivery of safe, sustainable and high-quality care. Leaders used data, audit findings, risk assessments, feedback and learning to inform improvements and manage risks appropriately.

The practice understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The practice demonstrated an understanding of the importance of partnership working and collaborated effectively with a range of healthcare providers and community services to support positive patient outcomes. The practice worked closely with its Primary Care Network (PCN) and other local providers to deliver services including extended access appointments, vaccination programmes and wider population health initiatives.

Staff described positive working relationships with community teams, care homes, pharmacists, social prescribers and other healthcare professionals. Regular multidisciplinary meetings and care home reviews supported information sharing, coordinated care planning and timely interventions for patients with complex needs and those at risk of hospital admission.

Feedback from the care home was positive regarding the practice's partnership working. Care home staff described GPs as approachable, professional and responsive to the needs of residents. They told us communication was effective and that the practice maintained regular engagement with the home to review residents' needs and resolve any concerns. The representative provided examples of how issues raised through joint working discussions were acted upon by the practice, supporting coordinated care and helping to improve the experience of residents and staff. This demonstrated a collaborative approach to delivering and improving care.

A member of the Patient Participation Group (PPG) spoke positively about their relationship with the practice and felt leaders were receptive to patient feedback. They told us the practice engaged constructively with the PPG and took account of patient views when considering service developments. The representative also described how the practice communicated regularly with patients through text messaging and other channels to share information about services, clinics, health promotion activities and healthcare initiatives. This helped ensure patients were aware of the support available to them and encouraged engagement with preventative and ongoing healthcare services.

The practice focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The practice demonstrated a commitment to continuous learning and improvement. Leaders used audits, clinical searches, significant events and patient feedback to identify opportunities to strengthen services and improve patient outcomes.

For example, following a review of asthma management, the practice introduced enhanced recall systems, patient messaging and clinician reminders to encourage timely follow-up after asthma exacerbations. Leaders also used patient feedback to review and improve aspects of service delivery, demonstrating a willingness to learn and adapt.

Learning was shared through clinical meetings, governance discussions and daily huddles, enabling staff to reflect on incidents, discuss best practice and implement improvements consistently across the service.

The practice also demonstrated a commitment to developing the future workforce. As a training practice, it supported GP registrars, GP trainees and foundation pharmacists within a multidisciplinary learning environment. At the time of our assessment, the practice was supporting two female GP trainees and provided protected learning opportunities, supervision and access to experienced clinicians. Leaders told us they valued the contribution of trainees and recognised the importance of investing in workforce development to support the delivery of safe, effective and evidence-based care. This approach promoted knowledge sharing, professional development and continuous improvement across the practice.