Lister House Surgery - Luton

Updated 14 July 2022

Lister House Surgery - Luton is located in Luton at

473 Dunstable Road,

Luton,

Bedfordshire,

LU4 8DG.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services, surgical procedures and treatment of disease, disorder or injury.

The practice is situated within the Bedfordshire, Luton and Milton Keynes Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 6,322. This is part of a contract held with NHS England.

The practice is a member of a primary care network (PCN) that enables them to work with other practices in the area to deliver care.

Information published by Public Health England report deprivation within the practice population group as four on a scale of 1 to 10. Level one represents the highest levels of deprivation and level 10 the lowest.

According to the latest available data, the ethnic make-up of the practice area is 48% Asian, 38% White, 9% Black, 4% Mixed, and 1% Other.

The age distribution of the practice population closely mirrors the local and national averages.

The practice has three male GP partners. The nursing team consists of an advanced nurse practitioners (ANP), a nurse practitioner, a practice nurse and a health care assistant, all female. There is a team of administration and reception staff all lead by a practice manager and a reception manager.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered an appointment.

Lister House Surgery is open from 8.30am to 6.30pm Monday to Friday with the telephone lines open from 8am. The practice offers extended hours on a Monday and Tuesday evening from 6.30pm to 8.30pm.

Routine appointments with a GP, practice nurse or health care assistant can also be booked through the practice for the Luton Extended Access Service. This service operates on Monday to Friday evenings from 6pm to 9pm and on Saturdays and Sundays from 8.30am to 2.30pm at two local GP Practices.

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 14 July 2022

We carried out an announced inspection at Lister House Surgery - Luton on 12 May 2022. Overall, the practice is rated as requires improvement.

The ratings for each key question are:

Safe - Good

Effective - Requires improvement.

Caring - Requires improvement.

Responsive - Requires improvement.

Well-led - Good

Following our previous inspection on 13 May 2021, the practice was rated requires improvement overall and for the key questions are services effective and responsive.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Lister House Surgery - Luton on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on:

• All key questions.
• Any breaches of regulations or should do actions identified in the previous inspection.

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.

This included:

• 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.

Our findings

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 requires improvement overall

We rated the practice as good for providing safe services because:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Safeguarding processes were in place to protect children and vulnerable adults.
• There were adequate systems to assess, monitor and manage risks to patient safety.

However, we also found that;

• Patient Group Directions were not all appropriately authorised for staff to administer the medicines.

We rated the practice as requires improvement for providing effective services because:

• The guidelines were not always followed when patients had an abnormal blood test result that could indicate a potential diagnosis of diabetes.
• The uptake for cervical screening remained below the 80% minimum target. However, there had been an increase in uptake from the previous inspection.

We rated the practice as requires improvement for providing caring services because:

• Feedback from patients was mixed about the way staff treated people.
• Patient satisfaction as demonstrated in the National GP Patient survey had declined. The practice had put an action plan in place to improve patient satisfaction. However, it was too soon to measure results.

We rated the practice as requires improvement for providing responsive services because:

• Patient satisfaction with how they could access the practice and book appointments was below local and national averages.
• The practice had put an action plan in place to improve patient satisfaction. However, it was too soon to measure results.
• The practice responded appropriately to complaints and made changes to the service when learning was identified.

We rated the practice as good for providing well-led services because:

• The practice had put actions in place in response to complaints and National GP Patient Survey scores.
• Staff reported they were supported by the GP partners and practice management.
• The practice had policies and procedures in place to support good governance.
• The Patient Participation Group (PPG) activity had reduced during the COVID-19 pandemic. The practice informed us that they had some difficulty restarting the group following the lifting of some of the COVID-19 pandemic restrictions as patients were reluctant to attend the surgery.

We found one breach of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.

(Please see the specific details on action required at the end of this report.)

The areas where the provider should make improvements are:

• Have a system in place to manage Patient Group Directions (PGDs) so staff are authorised to administer vaccinations.
• Continue to take actions to improve the uptake of cervical screening for all eligible patients.
• Continue to take actions to improve patient satisfaction with the service.
• Engage with patients and the PPG to reform the group.

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