Lister Medical Centre

On this page

• 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

There were gaps in governance systems and processes and we issued the provider with a Section 29 Warning Notice for failing to comply with Regulation 17, Good governance, of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We identified concerns with governance arrangements and the management of risks, issues and performance. There were significant gaps in the management of complaints. There was lack of oversight in areas such as infection prevention and control and medicines optimisation, for example, emergency medicines, management of blank prescriptions and cold chain monitoring. Staff also told us leaders were not always visible. We identified repeated errors with learning from significant events. However, we did find staff awareness of freedom to speak up was positive and staff were extremely knowledgeable on internal and local processes.

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.

Leaders told us they ensured their shared vision, strategy and culture had been developed through a structured planning process in collaboration with people who use the service, staff and external partners. They discussed any changes and future proposed changes with their patients via the Patient Participation Group (PPG). Some staff told us they understood the practice vision and values; however, some staff told us they were unsure if the practice had a clear vision for the future and some told us they had not been involved in developing the strategic planning of the vision and strategy. Staff described a busy, learning and evolving practice, a great, generally positive working atmosphere, although could become stressful at times. They were dedicated to deliver exceptional service to patients. Some staff found it difficult to work at reception due to the patient complaints. Leaders told us they had 4 away days this year to support decision making processes. We also received staff feedback that since the previous year, the practice had changed for the better; however, staff felt so many patients were being registered to join the practice, with very few being deducted when doctors worked only a few days a week so there were not enough appointments. Some staff felt the relationship between GP partners and staff could be improved. This was consistent with feedback received from patients raising concerns that the practice continued to register new patients but could not manage their current list size. They faced severe challenges accessing the service for both urgent and routine appointments via their total triage system and recognised patients also raised this new system as a concern. Staff also expressed concerns that different population groups such as children and those with mental health conditions should be able to get appointments with doctors and not everyone could use the online system which was fully booked by 8.30am and for most of the day.

The provider had a mission statement which was displayed on the practice website and a core values document updated in January 2024. They could demonstrate where they involved their practice team in vision and values. Although the practice had a clear view and strategy for the future and they aspired to deliver high-quality care but the significant barriers to patients accessing both emergency and routine appointments at the practice resulted in ineffective and unsustainable systems to deliver and monitor it. They described the new total triage system as transformational change; however, we were not assured leaders had insight, or were accepting of the risk to patient health and wellbeing posed by this new system. Our findings were consistent with both patient and staff feedback that the importance of flexibility, informed choice and continuity of care was not always reflected in the services provided and the barriers in access often led patients presenting to emergency services with non-urgent requests and their needs not being met. We saw evidence of discussions within their clinical governance meetings of any new initiatives and where feedback and comments were taken from staff regarding this. For example, the total triage system implemented in November 2023. We saw feedback from staff where they felt this system had a negative impact, particularly on reception staff on their ability to assist patients who required urgent and routine appointments.

We interviewed staff and some told us they felt that the leadership team were not always visible and there could be hours or days when they did not see them. Staff told us they wanted leadership to have more presence in the practice and this would lead to improved communication. Staff told us they had daily access for informal support with a learning supervisor and there was a learning supervisor in place each day to support learners and staff who required support. The practice manager had been supported to complete a Master’s Degree in Healthcare Leadership with the NHS Leadership Academy and the lead GP had also completed a leadership and business course. Leaders were alert to situations that would impact staff; for example, when they worked in an office with no daylight, staff discussed their concerns with their leaders and were moved to another office with daylight, creating a better working environment.

The provider placed visible signage on staff notice boards giving information on the Freedom to Speak up Guardian and their contact details were also visible. During clinical governance meetings and training events, whistleblowing policy was discussed and documented. We saw evidence that staff were encouraged to raise concerns and promoted the value of doing so. Staff were confident that their voices will be heard. There was a Freedom to speak up policy in place and the provider submitted a Freedom to speak up audit which would be a 2-cycle audit. The aim of the audit was to assess whether staff were aware of this policy and if they spoke up when they had concerns. 13 members of staff responded to this audit and the findings were that staff needed to be more aware of posters in the break room. Recommendations were to ensure new starters had this information and a picture of the guardian and how to reach out to them to be displayed for staff. Other recommendations also included hosting regular workshops on speak up. Further improvement was required to ensure all staff were aware of the Freedom to speak up guardian as 2 staff on inspection were not aware. There was a duty of candour policy in place.

We received feedback from 24 staff members as part of our assessment. Nearly all these staff members were able to tell us who the freedom to speak up guardian was, except for 2 of them. All staff we spoke with could clearly articulate how to escalate concerns, where to locate the policies, procedures and information for whistleblowing. Leaders believed staff morale had improved and this was largely be attributed to their open door policy. They told us staff often approached the management team to discuss any work related or non-work related issues or concerns and these were always heard fairly and in a non-judgemental way. They liked to be inclusive in feedback where 'everybody has a voice' also involve staff on their thoughts and opinions. However, some staff told us they wanted to see more of the leadership team as a significant amount of time would pass without seeing them.

The provider placed visible signage on staff notice boards giving information on the Freedom to Speak up Guardian and their contact details were also visible. During clinical governance meetings and training events, whistleblowing policy was discussed and documented. We saw evidence that staff were encouraged staff to raise concerns and promoted the value of doing so and staff were confident that their voices will be heard. There was a Freedom to speak up policy in place and the provider submitted a Freedom to speak up audit which would be a 2-cycle audit. The aim of the audit was to assess whether staff were aware of this policy and if they spoke up when they had concerns. 13 members of staff responded to this audit and the findings were that staff needed to be more aware of posters in the break room. Recommendations were to ensure new starters had this information and a picture of the guardian and how to reach out to them to be displayed for staff. Other recommendations also included hosting regular workshops on speak up. Further improvement was required to ensure all staff were aware of the Freedom to speak up guardian as 2 staff on inspection were not aware. There was a duty of candour policy in place.

The practice was an equal opportunities provider. There were policies in place for equal opportunities, bullying, harassment and anti discrimination. Leaders recognised how staff cared about their patients and noted how they took their roles seriously. They promoted a positive culture within the practice and staff were rewarded for exceptional performance. For example, when staff stayed late to await an ambulance with a poorly patient they were given gifts to say thank you for their patient care. This cultivated a positive feeling at the practice. When rolling out a new service, such as changes to the way service was provided, the practice engaged with staff and listened to their comments and thoughts. Concerns were discussed regularly during their clinical governance meetings, staff quarterly meetings and Time to Learn afternoons. They carried out a survey in 2022 by an external consultant which aimed to garner staff views on the practice. The survey received 39 responses and carried out 1 hour interviews with each of the 46 staff interviewed and the previous CQC report was also explored. Results showed 64% of staff felt the practice placed patients first, whereas peer average was 82% and 74% would be happy to recommend the practice to family and friends, whereas peer average was 86%. Positive feedback cited excellent premises, clinical governance meetings, included loyal, dedicated, valued and cared for staff with good pastoral care, pay, whilst negative feedback cited inadequate phone and patient access, poor communication, lack of leadership, staffing levels and inconsistent and confusing leadership issue between partners and management, lack of response to emails by leaders and lack of trust between staff and leaders amongst others; however, everyone wanted the practice to succeed. Recommendations included to recruit nurses as a priority, undertake a capacity and demand audit, improved communication, team building amongst other recommendations.

Although staff understood their roles and responsibilities, some expressed concerns that the practice had been without a lead practice nurse for quite some time. Some staff felt there were too many patients and only a few were being deducted, whilst more new patients were joining the practice. The integrated care board (ICB) told us between January and April 2024, the practice list size had increased by 1.8% from 20,037 patients. The GP Partners and managers had an overall responsibility for performance monitoring and ensuring staff were kept up to date. There was a lead GP partner for each clinical area and they told us they had a learning supervisor in place each day to support learners and staff who required support. Any concerns regarding a performance concern would be raised in a meeting with the other partners and management team. Leaders told us they took part in the national General Practice Improvement Programme. Leaders told us they had continuity plans to be able to continue service provision by the use of laptops, pre-printed lists of patients, communication to patients, notices, messages on telephony systems, the practice website and a buddy practice. They also told us practice staff were major incident trained. The provider had an agreement with an external provider to dispatch all paper records to them to scan and send them as attachments to the practice to include in patient notes. They told us they had risk assessed this process and were booked into a course in October 2024.

The overall governance arrangements were inadequate. Data was not consistently submitted to external organisations as required. The provider failed to ensure information we requested from them regarding their management of blank prescriptions was submitted to CQC as requested. Despite several attempts to engage and query this data with the leaders and the clarification of their processes due to a significant number of blank prescriptions being voided in a period of 2 months, the provider failed to respond. There was no risk management in relation to blank prescriptions and their monitoring systems despite previous significant events that should have led to improvements to manage this risk. We also found significant gaps in infection control, managing risks, actioning of some risk assessments and preventing recurrence of significant event themes, such as referrals. We also found gaps in mandatory training where up to 11 clinical and non-clinical staff were overdue their annual data protection training. There were also gaps in performance of the practice in relation to patient emergency and routine access and the impact this had on patient care, treatment and continuity of care. Gaps were also found in other areas such as, medicines management and although the practice provided evidence to show action taken to rectify issues we found in clinical searches, these improvements would be assessed at the next inspection to ensure the processes had been embedded and operating effectively. Staff signed a confidentiality statement when starting at the practice; however, we found gaps in information governance training; for example, 7 clinical and non-clinical staff were overdue their annual information governance training.

Staff told us they had a good working relationship with external stakeholders. Leaders told us they worked closely with care homes and hospices and had been completing some work projects with the integrated care board (ICB). Staff told us that communication internally was sometimes a challenge with lack of visible presence by the senior leadership team. We were told that communication was improving and the provider recognised more work could be done. We saw staff development conversations and opportunities were promoted and saw staff who had been given re-training opportunities for succession planning.

The Integrated Care Board (ICB) told us they had seen how hard the provider had been working since their last inspection and when they interacted with the provider, there was a visible difference in culture and positivity. The ICB also told us the practice implemented a total triage system in response to patient experience feedback utilising a working group and involving the Patient Participation Group (PPG). They felt the new online booking system improved patient experience. They told us their telephone system was also upgraded. We received negative feedback of the provider about poor communication and ineffective medicine reconciliation to the local care home. We were told that residents could be left without prescriptions and it was rare a GP visited the home on site. A weekly multi-disciplinary team meeting was arranged virtually and we were told that most consultations happened over the telephone and there was no pharmacist oversight currently. The care home manager had raised this with the practice previously and told us things were improving with medicines; however lack of GP presence was still a concern. We asked the provider to address their concerns. The provider told us shared care protocols were in place and the pharmacy team oversaw and ensured there was an up to date shared care protocol and if not, the practice clinical pharmacist would communicate with secondary care and patients. The practice also had an active Patient Participation Group (PPG) who praised the practice; however, felt management could do with more external support.

We saw evidence of collaborative working with the multidisciplinary team where they met monthly to discuss vulnerable patients, as well as close working with the ICB and integrated neighbourhood team (INT) involving the social worker, hospice, mental health and community matron. However, their responses to secondary care providers in relation to changes made to patient care that required their input was not seamless for people using the service. Although patient views were sought, they were not always acted on to improve services; for example, in relation to patient accessing the service. We also found verified, online patient feedback was not responded to. We saw evidence of PPG meeting minutes with the last meeting held in April 2024. We saw from the previous meeting with the PPG, members often raised the issue of access with the practice and fedback that patients often get through to the practice because the triage system was paused. The meeting minutes did not show how the practice responded to these concerns and despite external partners telling us the total triage system improved patient experience, this was inconsistent with the variety of feedback and survey results. We were not assured the practice always engaged with each other, there was a lack of transparency with blank scripts. Staff and leaders engage with people, communities and partners to share learning with each other that results in continuous improvements to the service. They use these networks to identify new or innovative ideas that can lead to better outcomes for people.

We were not assured of a strong focus on continuous learning and improvement. This was due to significant gaps and weaknesses in processes and arrangements intended to identify and deliver learning and continuous improvement in areas such as safeguarding, significant events and medicines management. We reviewed the practice significant events logs as part of our assessment. We saw a high number of significant events between December 2023 to July 2024, there had been 45 significant events. As with findings from our inspection, examples seen were incorrect emergency medicines, poor patient care and fridge monitoring data errors. The practice told us learning from events was discussed, however, the significant events reviewed showed repeated errors, despite being discussed in clinical governance meetings. Similarly, we reviewed the practice complaints data and there had been a high number of 76 complaints received between February 2024 and July 2024. We reviewed 5 complaint responses and only 3 of these had details of how to escalate a complaint to the Parliamentary and Health Service Ombudsman. There was evidence of information sharing in some areas, such as with the integrated care team but sharing between practice staff and during periods where staff were absent when meetings were held, there was limited of sharing information.