Lister Medical Centre

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We recognise the pressure that practices are currently working under and the efforts staff are making to maintain levels of access for their patients. At the same time, our strategy makes a commitment to deliver regulation driven by people’s needs and experiences of care. Although we saw the practice was attempting to improve access, this was not yet reflected in the GP patient survey data and various sources of patient feedback, such as complaints sent to CQC and online feedback. Patients faced significant barriers to accessing care from the practice and significant concerns were raised about their new total triage system. We observed how this system was unable to meet the patient demand at several points during the day, leaving some patients completely unable to access any care from the practice. There did not appear to be any workaround this issue. Therefore, the rating is requires improvement, as ratings depend on evidence of impact and must reflect the lived experience that people were reporting at the time of our assessment.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patient Participation Group feedback from their meeting in April was that one patient said that trying to book an annual review was impossible on the triage service as all the questions needed to be answered. Patients concerns with accessing the practice had an impact on the effectiveness of people's care and treatment.

Leaders told us there was an anti-discrimination policy and all staff, except one clinician had completed their equality and diversity training. The practice told us they took note of any specific requirements highlighted by the patient and their specific wishes in planning care. The practice told us they accommodated double appointments, interpreters, times of appointments for working patients, chaperones, weekend clinics via enhanced access. They also told us peoples wishes for appointments were documented on their medical records and were accessible for staff who booked appointments. Information was given to people for them to make an informed decision of their care based upon all information available. However, this system was not working due to the limitations of total triage and the inability for patients to book in person, leading to poor access to the service for patients. This had a direct impact on the provision of person-centred care. Staff told us changes made from secondary care were discussed with patients and the pharmacy team would monitor a persons shared care agreement to ensure it was current and up to date. However, we found gaps in these processes because patients could not access the service to ensure changes to their medicines were made in a timely manner. Staff told us reasonable adjustments were made where required. For example, they told us they supported a patient with mental health issues who was unable to attend a busy GP practice by arranging for them to be seen in a quieter environment. A quiet area of the practice was used to obtain blood tests and an annual review of the person's care and medicines.

Staff and leaders told us people received care and treatment from services that understood the diverse health and social care needs of their local communities. They told us they worked with the community pharmacy based on site. They told us working with their local pharmacist worked well and they had the highest number of referrals into the service in the locality, which led to improved access for their patients. Leaders told us they worked with the local Citizens Advice Bureau to support patients with social and financial support. Staff told us they were involved in and facilitated in hosting a lung cancer project with diagnostic machinery located in the practice car park.

The local integrated care board indicated the provider had the most community pharmacy referrals for the region. They told us they used the Pharmacy 1st service where patients were signposted to the pharmacist for 7 common conditions such as, minor ailments, sprains, aches, colds, headaches, rashes, cystitis and antibiotics could be prescribed. We received feedback from their assigned care home, Abbott Care home. They told us the practice carried out weekly mostly virtual ward rounds and weekly multidisciplinary team meetings with them. They told us medicines reconciliations were not always effectively managed, including when different pharmacies were sent their prescriptions. They felt the service they received from the practice was improving but not enough and they preferred face to face visits.

Proactive care meetings were held within an integrated neighbourhood (INT) team, where they discussed high risk patients. Members of the INT included social workers, mental health teams, hospices and community matron. These high risk cohort of people would be reviewed for the best community support available to prevent hospital admission. Feedback showed this integrated neighbourhood team was reducing the number of unnecessary hospital admissions. The practice social prescriber supported patients with housing, benefits and obtaining signposting to community services. We found gaps in care provision that mean people's care and treatment was not always delivered in a way that met their assessed needs from services that were co-ordinated and responsive. Patient feedback reflected gaps in communication between the GP and pharmacy. For example, a patient's monthly prescription for their inhalers was delayed for 3 months in a row, despite requesting their prescriptions a week in advance. This often left the patient at risk of running out of his prescribed treatment. We also found patients experienced significant difficulty receiving co-ordinated care due to poor access and the practice not responding to complaints.

People told us they did not always receive accurate information from the practice. One patient was told to attend accident and emergency for a non-urgent medical problem. People also told us they had experienced unacceptable delays from the practice where they did not issue a death certificate due to staff annual leave. Additionally, the letter response from the provider was dated 5 October 2023 but they received this on 19 October 2023 and still failed to address their queries and concerns. During a meeting with the provider, the Patient Participation Group they raised concerns that they were not provided with further information once their online appointments requests were submitted.

The provider told us they complied with the Accessible Information Standard. They told us for patients who English was not the first Language, or deaf and sign language users they could access other provisions, such as a hearing loop at the reception desk. The practice would make reasonable adjustments to support patients who had neurodiversity or communication barriers. People could make subject access requests and their medical records and online access were available. The provider also told us when accessing the practice website, people could zoom text to 300% for easy read text and there were different coloured views for neurodiverse people. They also told us that speech recognition software could be used to access the practice website. People were asked to tell the practice how staff could best communicate with them and this formed part of an annual review. They told us people could make subject access requests for those wishing to access their records and there was an online access policy.

The provider complied with the Accessible Information Standard to make provisions for those hard of hearing. We saw the practice support people with protected characteristics. The care co-ordinator and link workers supported people to signpost accordingly to places such as St Clare’s hospice bereavement café and there was a bereavement champion in place at the practice. However, we were not assured that people received information in a timely way that met best practice standards, legal requirements and tailored to individual need, in particular delays in referrals to the coroner for deceased patients. From evidence we reviewed, we found 2 cases and in one case, the coroner had to chase the GP for a report. In another case we reviewed, people who experienced bereavement were not provided with timely information as there were severe delays in issuing a death certificate and the information provided to families was not clear and transparent. In this instance, people had raised concerns that there was an unacceptable 18-day delay in referring the deceased patient to the coroner, which meant the registration of patient death had breached the 5-day statutory guidance to register deaths. The provider responded by telling the family that the practice manager and GP had both been on leave and not contactable but there was no reasonable explanation from the practice as to why this impacted on an 18-day delay in issuing a death certificate and the impact this would have on people. The provider told the family the relevant staff had gone on leave, suggesting there were inadequate processes in place to ensure relevant staff managed such time sensitive tasks in a timely way, prior to going on leave and delegating to other staff members in order to meet statutory deadlines.

People knew how to give feedback about their experiences of care and support including how to raise any concerns or issues. They could do so in a range of accessible ways, such as via the practice's website in the compliments section, submitting informal and formal complaints to the practice, written online NHS and unverified google feedback and sending their feedback to CQC and completing Friends and Family tests, as well as the national GP patient survey. People, their family, friends and other carers did not always feel confident that if they complained, they would be taken seriously and treated compassionately. They also told us responses to their complaints were either not received, or not received in good time. For example, we received concerns that patient complaints were not being responded to, including when the practice was chased and for some patients, it took 2 months for the practice to acknowledge their formal complaints. Even when raising informal complaints, people felt this was to no avail and some reported concerns that the provider would assign their complaints to junior staff to contact them instead of practice management. We also received feedback that patients that when they managed to have an appointment with a clinician, their symptoms were often brushed off until they got worse. Other feedback provided by patients online included concerns around poor staff attitude and some long-term patients told us they tried to raise informal and formal complaints with the provider but did not get any sort of reply from the practice even after 2 months. We reviewed 8 compliments from people posted on the practice website in the past year. People said when they had appointments with their GP they felt heard and listened to.

The practice told us learning from complaints and concerns was seen as an opportunity for improvement and staff could give examples of how they incorporated learning into daily practice. GPs told us they would receive support from their Medical and Defence Union (MDU) to draft responses when complaints were raised against them. However, 5 administration and nursing staff told us via their feedback forms that they were not made aware of complaints and others were sometimes made aware of them. Staff also told us that patients would ask to speak to the managers; however, there were no such options as complaints had to be raised via email only. They also told us staff could write emails to the management on behalf of the patients and described having to write an urgent email to the practice manager on behalf of a patient when the patient had not received a response to a previous complaint. Staff we spoke to told us they felt listened to and supported. They could raise concerns and their feedback was collated and discussed during practice meetings.

Patients could access complaints information via the website and notice board. The process in place was to acknowledge complaints received within 3 days. However, these systems to acknowledge and respond to peoples complaints were not operating effectively. Despite the practice website stating people could ask to speak to the practice manager, this was not an option and according to staff, patients were told to send emails instead. People were not always kept informed about how their feedback was acted on. The practice did not respond to any online NHS reviews and some patients told us that their complaints went unresolved by the management. The provider was aware they did not respond to NHS feedback and told us they would put an action plan in place. We were concerned about the number of complaints that were not responded to, or where there were delays in responding; for example, 2 months. We reviewed 5 complaint responses and identified 3 of those did not have details of the Parliamentary and Health Service Ombudsman. There was no complaints policy despite requesting this as part of the assessment. Friends and family testing was sent out weekly at the practice and leaders told us there was a process of gaining patient feedback after each contact with the practice. Whilst we saw evidence of complaints being discussed in the various meetings including the reception meetings, we also saw evidence from complaints where the management had not responded to patients in a timely manner and told them this was due to the practice being short staffed.

People's experience of the practice's new e-consult appointment system was consistently negative and they felt it was not working. Patient feedback on their experience of trying to access the practice obtained from different channels such as NHS reviews, google feedback and patient complaints sent to the practice was increasingly negative. We saw 21 patient complaints sent to the practice in the past year and to CQC where people said they could not access appointments via the new online booking system. This was in addition to all other feedback. Patients described this new total triage system as making a bad service worse, some said it was 'atrocius' whilst others raised this with their MPs. People told us even if they visited the practice in person due to not being able to access the online booking system, they still faced barriers in making appointments and were advised to leave and try the online portal again. Patients described that they would request an urgent appointment at 8am and by 2pm there was still no contact from the practice and some reported no access to the booking system at all after 12pm. Others said they unsuccessfully tried to book appointments at the practice for 4 days. We reviewed 8 compliments posted on the practice website where some people fed back that they got registered on the day and received an appointment that same day. We reviewed the 2023 national GP patient survey results and found only 23% of patients found phone access easy and this was a negative outlier compared to the national average of 50%. 38% of patients responded positively to the experience of making an appointment and this was lower than the local average of 49% and national average of 54%. Only 36% of patients were satisfied with their appointment times and this was lower than the local average of 47% and the national average of 52%. 62% of patients were satisfied with the appointments they were offered but this was lower than the local average of 69% and 72%.

The practice told us patients could place an online triage request instead of calling the practice and this request would go to the duty GP to review. They told us this was to free up the telephone for those who could not access the technology on a smartphone, or for those who did not have a computer, in which case they could contact the practice by telephone or attend in person. Some staff told us this total triage system gave patients a better chance of getting an appointment and this had a major positive impact. However, this feedback was significantly inconsistent with patient feedback where they reported poor telephone access and a complete inability to book any appointments in person when they came in to do so. We saw evidence of staff feedback from several meeting minutes where reception staff reported feeling less helpful to the patients as all appointments were booked via total triage and they expressed how they felt deflated and morale was low. Not all appointments were self-bookable. The practice provided their triage access data from January 2024 covering 6 months. They told us 22,433 requests were submitted in total, 18,764 of which were medical requests. This was an average of 134 requests a day, 87% via the website and 13% via the reception. There was no data provided to show how many of these requests resulted in appointments being offered. The most recent audit for January 2024 showed 38% of patients found overall experience of accessing their GP as good. Staff told us people who required assistance or assistive technology were able to ask the administration team for help to complete forms or make appointments. The practice undertook their own deep dive audit into the reasons patients found telephone access difficult and the results showed the online appointment system for booking appointments required adjusting to give more accuracy to reporting.

The practice total triage system was introduced in November 2023 and we were not assured that it was working. The PPG was told the provider had 1 medical sifter a day and when the system opened at 8am, 125 requests would arrive within 45-minutes and it would take 2 hours to get through some of the submissions which would be cleared by midday, whilst the system was temporarily closed. The clinician would then look at the rest of the day and the following day to see how many appointments were left and decide if they would be able to switch the system back on again. The clinician did not want to accept more submissions if there were no appointments. Despite telling us patients still had an option to call or attend the practice to book routine, chronic review and nurse appointments; this was not consistent with our findings that access was significantly reduced, if not impossible for most patients. We attempted to access the practice triage form one morning and by 10am patients were told, 'We have paused access to online requests as we have reached capacity for our doctors to safely deal with today's requests' We attempted this after 12pm and found patients were met with the same message. Appointment requests were stopped once full and there was no discretionary pathway for emergency appointments, patients were placed at risk of harm and the practice could not manage the number of patients in the practice. The GPs provided 48 clinical sessions a week. Extended hours appointments were available at the weekend and provided by an external provider, Stellar Healthcare. Extended Access and Out of Hours services were offered through Herts Urgent Care who were based on the first floor at Lister Medical Centre. The practice provided an extended access survey of which 60% of 603 responses were Lister patients. Data showed of these patients, only 11% agreed they could access a routine GP appointment and 67% disagreed.

The Patient Participation Group (PPG) supported the practice to shape service enhancement by giving valued patient feedback obtained into service provision or any specific needs that would support people. People’s care, treatment and support promotes equality, removes barriers or delays and protects their rights. People feel empowered by providers and staff to give their views and understand their rights, including their rights to equality and their human right. People feel that their experiences of discrimination and inequality are listened to and acted on to improve care. Some people felt the practice was taking on too many patients than it could manage to care for.

The provider's statement of purpose was 'to show our patients courtesy and respect at all times irrespective of ethnic origin, religious belief, personal attributes or the nature of the health problem'. Leaders and staff told us they were alert to discrimination and inequality that could disadvantage different groups of people using their service. They proactively sought ways to address these barriers to improve people’s experience, act on information about people's experiences and outcomes and allocate resources and opportunities to achieve equity. They told us they had a dedicated services for interpretation and for patients who require British Sign Language. They told us they 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. They also told us there was a dedicated baby breastfeeding room and there were at least 2 isolated rooms, one by the centre entrance that patients could use if necessary.

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. People were able to use services such as hearing loops, email communication, online real time consultations and there was readily available large print or pictorial guides. The premises was a purpose built building that included wheelchair access and 2 lifts for people to use. Volunteers would support the provider to signpost and support people and the PPG would support staff to refer and signpost to services. Interpreter services were available and home visits took place for their housebound patients. The practice website had an accessibility statement which explained to patients that they could zoom to 300% to make text larger, view in different contrasting colours and navigate using just keyboard or speech recognition with the right technology. People who required additional support were invited at quieter periods and tailored adjustments suitable for their needs or preference. Jayex calling boards were used for people to know when their appointment was available. Previously the practice had worked with the primary care network on a commissioned survey to help positive changes for enhanced access services for people in the local area. This was being completed annually to help gain a localised view of what services would be of most benefit to people.

We did not receive any patient views with regards to end of life care.

The practice told us a frailty toolkit was going to be implemented for any age adult deemed likely to be in last year of life in order to provide holistic assessment of needs. Leaders told us as part of the ECF requirements, clinicians were encouraged to think about patients with chronic illnesses such as COPD and heart failure as potential end of life patients. They told us templates for the chronic disease reviews were updated to prompt question if applicable, as well as another dedicated end of life template which if not completed the alert would stay on the patients’ home page. The practice had a close working relationship for any patients who required hospice support and they assisted in the completion of the PEACE document, a proactive enhanced advance care (PEACE) plan which was a non-mandatory document to help health care professionals deliver the best care to people with life limiting illness. The local pharmacy would prioritise end of life medicines for people. Some staff told us they attended meetings at the local hospice and also attended a few cancer information events such as, One step at a time.

The practice held a monthly multi-disciplinary (MDT) meeting where people with chronic illnesses or potential end-of-life people were discussed as part of a monthly review. One of the salaried GPs had completed a fellowship programme in frailty patients. People who may be approaching the end of their life were identified and people who wanted to express their wishes about cardiopulmonary resuscitation, they were supported to do so and change their mind if they wished. The MDT care co-ordinator reviewed any end of life including any applicable anticipatory medicines. The DNACPR documentation was completed on the record and discussed with patients and the relevant 4 patient DNACPR records we reviewed demonstrated this. They worked working closely with St Clare hospice and the end of life care nurse at the hospice and with the local community pharmacy to make sure emergency drugs were available in a timely manner.