Lister Medical Centre

On this page

• 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 rated the practice requires improvement for providing effective services because patients’ needs were not always assessed and care and treatment was not always delivered in line with current legislation, standards and evidence-based guidance. However, we saw evidence that the provider proactively sought ways to address barriers to improve people’s experience. The practice complied with legal equality and human rights requirements, including avoiding discrimination, having regard to the needs of people with different protected characteristics and making reasonable adjustments to support equity in experience and outcomes.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We reviewed people's experience from different sources, some of which included NHS reviews and feedback sent directly to CQC. We found feedback was mixed in relation to how their needs were assessed and routine review of their care needs. Some patients fedback that when they tried to obtain an assessment as a new patient, they were told they could not just book an appointment and had to wait. Other patients said that the inability to access their systems prevented patients obtaining triage assessments and there was no discretionary pathway for emergency appointments. We reviewed patient feedback sent to CQC and some patients told us their needs were not assessed due to poor access and they were often told to go to accident and emergency for general or minor illness. Patients told us their communication needs were often not assessed and elderly patients who could not use a computer and who could not access the practice by phone were often left without care and treatment. One patient who required an urgent assessment for an abnormal growth told us they had unsuccessfully attempted to obtain an appointment 10 times but none were ever available, so they felt there was no service at all. Some patients told us of their positive experiences with the practice; however they were not the majority; for example, we received only 3 positive people's experiences in the past year. One positive experience included where a patient was assessed by a medical doctor and felt the experience went well and another patient told us they were offered a same day face to face appointment, which was changed to a telephone consultation at their request. This patient told us they received their appointment, sent for tests and a referral made.

The practice told us they carried out NHS health checks for patients aged between 40 and 74 years and senior NHS health checks for patients aged 75 and over. They told us they had their own list of types of vulnerable patients such as learning disability, mental health, dementia and sensory deficit. Patients were contacted by their preferred method of contact, often telephone by the personalised care team to arrange for their annual health checks. The practice told us they had a good recall system using a one stop shop to ensure people's care needs were routinely reviewed. They told us they had mental health care coordinators used to facilitate care and the needs of palliative care patients were discussed during their monthly multidisciplinary team meetings. The practice used a clinical system to record and manage patient information. They told us they also used the Rockwood score to measure frailty index and dementia screening tools for those with suspected dementia. They also had inhouse mental health practitioners and told us that any patient with a mental health problem and after risk assessment, there was a concern the patient was immediately referred to the duty doctor. They also told us they referred to secondary care and, or crisis team as clinically indicated. Whilst we saw evidence that the practice proactively sought ways to address barriers to improve people’s experience; for example, initiating a call back service to reduce long waiting times on the phone and introducing the Pharmacy 1st service where patients could be assessed by the pharmacist for 7 common ailments, we found the inability to access the practice prevented patients obtaining timely triage assessment or signposting to an appropriate service.

The provider had some shortfalls in assessing needs and had implemented an action plan following our remote clinical searches to demonstrate their willingness to improve. However, these improvements will be assessed at the next inspection to ensure processes are embedded. Although we found evidence of effective care for patients already diagnosed with diabetes, where we did not find significant concerns and patient monitoring was up to date; we found people's chronic disease management in other areas were not always routinely reviewed. For example, there were 4 out of 555 patients prescribed thyroid medicine who had not received the required monitoring. Our clinical searches found although steroid emergency cards were being issued for patients diagnosed with asthma, not all eligible patients were issued one. Our searches found 55 out of 1921 patients diagnosed with asthma required a steroid card. We also found 7 out of 45 patients diagnosed with chronic kidney disease 4/5 had not received the required monitoring. The provider had a learning disability register of 109 patients and only 8 of these patients had completed health checks in the past year. The practice told us 3,263 patients were eligible for an NHS health check but data provided showed only 92 checks had been completed between April and July 2024. There was a carers protocol in place to identify and add them to the carers register, where alerts were placed on their records, needs assessed, received chronic disease reviews and joint patient and carer discussions during consultations. There was a practice Carers Champion and they were offered annual health checks, care coordinator oversight and input from a social prescriber. Practice data showed 358 (1.7% of the practice population) including 3 young cares were on the carers register. The NHS GP patient survey showed 72% of patients felt their needs were met during their last GP appointment and this was lower than the local and national averages of 90%.

We received mixed feedback from patients regarding good practice that was relevant to their care. We saw examples from NHS feedback where patients were happy with the care provided once they were able to access the service; for example, one patient praised the practice for the care they received since being diagnosed with diabetes and felt clinicians were knowledgeable. However, the majority of people expressed issues relating to the inability to see an actual GP which led to patients experiencing abnormal symptoms being unable to receive urgent assessment as per guidelines. One patient told us they were suffering from a urinary tract infection but due to not being able to get an appointment with the practice, they were advised by reception staff to go to accident and emergency instead, which was not in line with guidance or good practice. This patient ended up receiving treatment from a private provider. Other patients expressed difficulty in obtaining GP appointments and whenever they received appointments, their symptoms were not adequately assessed and dismissed until they got worse. Following this, they were told they had been referred to the local hospital but they were not provided with any details such as what department or contact information, leaving them to wait for a month now without an appointment. We also received feedback from parents that children were not treated with compassion and parents did not feel listened to and involved within their children's care. We received negative feedback to some clinicians being rude and dismissive when assessing patient needs and other patients also told us they did not receive the required diagnostics when required.

Leaders told us they followed the National Institute of Clinical Excellence (NICE) and other national guidelines. They told us they attended Time to Learn events 8-10 times per year, as per the integrated care board schedule, which supports training for clinical staff in various areas. They told us any urgent updates on training were sent via email to all appropriate staff and they were looking into utilising TeamNet for dissemination of information in the future, via a Digital Transformation Lead recently recruited. Emergency care practitioners and GP's told us there were clear processes for assessing patient needs and these would be followed up with clear safety netting instructions. They also discussed their systems in place regarding patient safety alerts and the evidence based guidance and we saw evidence of this.

We saw evidence of the practice following national guidelines such as NICE and discussing them at their monthly clinical governance meetings, as well as undertaking recent audits to ensure compliance with these guidelines, such as the unopposed oestrogen and antibiotic prescribing audits. We saw clinical governance meeting minutes to show where current national guidelines were discussed. As part of our assessment, we completed remote clinical searches to ensure people received care, treatment and support that was evidence-based and in line with good practice standards. We found the practice had some robust systems in place in relation to the patient safety alerts and some areas of long-term condition management such as the monitoring of patients with hypothyroidism; however, there were also significant gaps in the management of other long-term conditions. For example, we found there were 1,921 patients diagnosed with asthma. Of these, 73 had been prescribed 2 or more courses of steroids. We identified a sample of 5 patient records that showed the consultation notes and issuing of steroid cards were not always detailed with enough information and records were missing detailed information required for an asthma review and we found one patient had not received an asthma review since 2017. There were 22 patients who had a potential missed diagnosis of diabetes. The provider told us these patients were monitored, however we found the practice was not following the national guidelines in relation to repeating blood tests for abnormal average blood sugar levels, as we saw an example of a patient who was still waiting a follow up blood test 13 months from the first. Another patient was showing as possible diabetes and had not received a follow up or a diabetic review for 12 months of the blood test confirming diabetes and required an urgent follow up.

People's experience was mostly negative about their care and did not always feel their care was co-ordinated effectively, or that there was effective continuity of care due to significant issues around accessing the practice that hindered this. Several people told us of their negative experiences when trying to arrange their continuity of care when transitioning from secondary to primary care and they told us in some cases, their secondary care teams would unsuccessfully try to contact the practice to ensure follow up of these patients was taking place. One patient told us every time they had an appointment they only saw a triage paramedic and not their nominated doctor, despite having a persistent cough for 2 weeks. They told us it took 3 months and 3 appointments for the staff member to consider a test for cancer. Another patient told us he required a referral to the elective spine services from the GP; however, they told us the practice had stopped telephone requests for appointments and this needed to be completed online. On attending the surgery, patients were told they could only book online appointments and there was nothing reception staff could do, so at the time of contacting CQC, the patient had not been able to access the practice to discuss the referral. Other patients raised concerns of a delayed referral to cardiology when diagnostic tests had shown abnormalities that had been discounted by the GP, 2 months prior. When we reviewed verified NHS reviews, we found some positive feedback with regards to collaborative care where one patient was assisted by 3 members of staff when they were bleeding following a blood test. However, the majority of patients continued to raise concerns about the lack of continuity of care due to poor access; for example, one patient reported that they could not obtain their x-ray results as no one was answering the phones. Another patient reported poor communication between the practice and the pharmacy.

Staff told us they worked effectively across the teams to support people. For example, patients had access to the diabetes nurse and an inhouse mental health practitioner, so any patients with mental health concerns were immediately referred to the duty doctor if after a risk assessment issues were identified. Staff also told us they referred patients to secondary care, or the crisis team as clinically indicated. They also shared clinical details with specialists as appropriate and needed when referring children to adult services. Staff told us they held monthly clinical governance meetings, quarterly whole practice meetings and multidisciplinary team meetings. They also told us information was shared at 6-weekly significant event and safeguarding meetings. TeamNet was used to upload meeting minutes but we were not provided with evidence of whole practice meeting minutes. Leaders told us shared care was discussed with patients and carers, including any changes from secondary care. The pharmacy team ensured shared care agreements were up to date and communicated to patients in person or via telephone. Leaders told us they worked well with the onsite community pharmacy and the practice had the highest number of referrals into the service in the integrated care board (ICB). They told us this led to improved access for their patients. They also told us they had proactive care meetings with their integrated neighbourhood (INT) team, where they discussed high risk patients. They also told us they were working with the Citizens Advisory bureau in order to support patients with social care, financial and other advice run by members of the CAB.

The local integrated care board (ICB) told us the practice had been positively working on practice improvement and there were no significant changes to leadership over the last year. The ICB also told us the practice have implemented a total triage system in response to patient experience feedback utilising a working group and involving the PPG. Their telephone system was also upgraded. They had signed up to improvement programmes and were showing over the month of May 2024, increases to their data reporting. The practice local medical council had also shared with us the improvements seen made by the provider. The designated care home for the practice told us they held weekly multidisciplinary team meetings with the practice and virtual ward rounds mostly took place and face to face, or telephone appointments were only if the practice GPs were requested; however, they told us they preferred the practice to carry out face to face patient visits. They reported that at times there were gaps in communication and they found different pharmacies were sent their prescriptions instead.

The processes in place did not always demonstrate effective working across teams. We found clinical tasks were not delegated in a timely manner and we also saw evidence of clinical governance meetings and significant event meetings but it was not clear from the evidence provided who attended the clinical governance meetings, or how the practice assured themselves that those that could not attend were followed up to ensure they read meeting minutes and were aware of the actions arising from them. We saw evidence of care managed collaboratively with the diabetes specialist nurse to ensure safe, continuity of care and manage risk to diabetic patients. For example, they had a dedicated diabetic nurse based in the practice and they worked collaboratively by setting up monthly batch reporting so they could refer patients who had higher than normal average blood sugar levels and had not receiving blood test monitoring in 6 months. These patients would then be invited for bloods and interim reviews by the practice care co-ordinator team. However, we also found delays in co-ordinating patient care and mobilising different services for patients that required urgent assessments. For example, we received concerns that one at risk patient who lived alone, recently discharged from hospital and diagnosed with dementia and on multiple medicines could not access the practice to discuss a reassessment for urgent social services and care package assessment. This patient had been discharged without the correct care package in place and although the practice acted on the complaint, there was a 2-week delay in the practice co-ordinating this patient's care. We also found patients who were on hospital issued methotrexate were not always on the correct dose. One patient's dose was increased by the hospital 3 months prior but had not been picked up by the practice on the hospital document. This placed the patient at risk of harm due to not acting on hospital letters in a timely manner.

The latest NHS national patient survey results for the past year showed only 35% of patients said they had enough support from local services or organisations in the last 12 months to help manage their long-term conditions or illnesses; however, this was lower than the local and national averages of 68%. There was mixed feedback regarding people's experiences relating to being supported to manage their health and wellbeing. When we reviewed online NHS patient reviews, some patients felt their inability to access practice systems prevented the practice from signposting patients to appropriate services. Whilst compliments posted on the practice website praised an informative information session spending quality time explaining their health issues and adapting lifestyle to maintain a healthy life now and in the future, various feedback channels described how poor access to the practice was not allowing them to manage their health and wellbeing effectively. We interviewed a patient during our onsite inspection who told us that during a consultation of chronic disease management, the clinician would discuss lifestyle management; for example, exercise benefits and healthy eating. However, due to the significant number of concerns raised by people using the service regarding what they described as completely impossible access systems, some patients feared what impact this had on people's health and wellbeing.

Staff told us they encouraged participation in national screening programmes such as bowel, breast and AAA screening. The practice told us people were able to self book NHS health check appointments that were suited to their needs. The practice told us this was done by promoting the uptake of NHS Health Checks by sending self-book online links with information attached. This was also replicated for cervical screening. Staff told us they covered lifestyle management such as, smoking cessation, exercise and diet or weight management during the completion of the chronic disease reviews. Staff also told us they would use every possible opportunity to promote health and wellbeing. Leaders told us they were in progress of discussing a well woman service and initial feedback had been positive. They were liaising with the local integrated board to discuss funding for this service. The aim was to improve uptake of cervical screening and supporting menopause changes and how this impacted on a woman's life. The practice told us they were involved and facilitated in hosting a lung cancer project with diagnostic machinery located in the practice car park.

There were processes in place to support people to live healthier lives; however, further monitoring was required to ensure the risks to people's health and wellbeing were always identified early and people supported prevent deterioration. For example, we found 22 patients had a potential missed diagnosis of diabetes and when we reviewed 5 of these patients, there was no evidence they had been referred to eye screening to detect early eye damage and prevent deterioration in eye health. The practice had access to a social prescriber employed within their Primary Care Network, whose role was to support patients and signpost them appropriately to other services as required, to support them in their health and social needs. However, the policy in place did not clearly explain the scope of this role and what it entailed on a daily basis; for example, what type of services were being referred to and the type of needs that would fit the criteria for a social prescriber referral. Patients could access information to manager their health and wellbeing via the practice website which contained a health information section which included self help and living well advice, carers information as well as a link to mental health assessment tools, different mental health organisations and a mind plan to help maintain and improve mental health and wellbeing. Nursing staff offered vaping smoking cessation therapies and worked with relevant partners to identify the best outcomes for patients. The practice referred patients to the weight management enhanced service; for example, those with hypertension and other illness. In March 2024, the practice were carrying out the most referrals in the locality. The Office for health improvement and disparities data for April 2021 to March 2022 showed the provider had a 38% cancer detection rate, which was tending towards an outlier, as it was lower than the national average of 55%.

People felt the provider's approaches to monitor their care and treatment and their outcomes was greatly impacted by lack of access to the practice. People told us they could not book appointments online and this included for their cervical smear appointments.

The provider told us they were always seeking innovative ways in which they could improve on peoples outcomes and experiences; for example, through a wide range of surveys and audits. They recognised a high prevalence of diabetic people and employed a specialist diabetes nurse to support with diabetes care and monitoring.

The practice had processes in place to monitor and improve outcomes but they were not always effective. For example, we found 7 out of 45 patients with Chronic Kidney Disease Stages 4 or 5 had not received the appropriate blood test monitoring in the last 9 months. Published results showed the uptake rates for cervical cancer screening were below the 80% target for the national screening programme. Data from March 2023 showed uptake at 72%. Data for breast and bowel cancer screening rates for March 2022 also showed the practice below target at 66%, whilst national average was 72% and bowel cancer screening rates were below target at 60%, whilst the national average was 66%. However, we saw evidence of effective processes in place in other areas, such as quality improvement activity which included undertaking 2-cycle audits. For example, they carried out an audit on the use of a statin medicine in cardiovascular patients. The result of this audit showed 28% of the 37 participants had successfully changed medicine to support them to have an improved cholesterol level and fewer medicines taken daily. Initial feedback had been positive. Other audits had been carried out to monitor and improve outcomes for patients with acute coronary syndrome post discharge from hospital, monitoring and improving outcomes for patients diagnosed with heart failure, chronic kidney disease and diabetes prescribed SGLT2 medicines, used to threat these conditions. Immunisations were slightly below expected national averages. Cervical screening was slightly below with national averages. The implementation of the cervical screening clinics was improving uptake following analysis of patient feedback; however, we found patients inability to access the service had an impact on the uptake of cervical screening in the practice.

We received patient feedback raising concerns that a child was registered with the practice without the appropriate parental consent or documentation, resulting in a potential risk to the child's safety. The practice also received 2 other consent related complaints in the past year.

Staff told us that they found the decision making guidance useful and it had enabled them to work with people, parents and children effectively to make consent decisions with ease. They described a partnership approach to people. Staff could express confidence to where policies and procedures were kept, how to locate them and when to escalate concerns. Leaders told us staff applied Gillick and Fraser competencies as appropriate.

Peoples wishes and decisions were recorded and consent documented to show agreement. Any legal paperwork to support a person's care plan was placed into the persons medical records, for example, an advanced care plan. There was a Do Not Attempt Resuscitation (DNAR) policy in place for staff when making decisions for cardiopulmonary resuscitation. When we reviewed their clinical records, we found 5 patients had a DNACPR forms in place. Where a person lacked capacity, staff would hold their power of attorney documentation within their medical records. Staff were able to see a flagged message when making appointments which alerted the person would require their power of attorney present. There was a mental capacity policy in place. The provider would review mental capacity decisions annually unless the patient needs changed and then this would be completed sooner. All applicable patients had a DNAR form and this was reviewed with each consultation to ensure patients views were documented. Care plans and advanced directives were reviewed within a patient consultation and all changes would be documented. Non-clinical staff we spoke to were aware of Gillick competencies. At the time of inspection, three clinical staff were overdue their mental capacity act training.