The Care Quality Commission
  • Doctor
  • GP practice

Lister House Surgery - Luton

Overall: Requires improvement read more about inspection ratings

473 Dunstable Road, Luton, Bedfordshire, LU4 8DG (01582) 578989

Provided and run by:
Dr Ihonor and Partners

All Inspections

12 May 2022

During a routine inspection

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

13 May 2021

During a routine inspection

We carried out an announced inspection at Lister House Surgery - Luton on 11 – 13 May 2021. Overall, the practice is rated as requires improvement.

The ratings for each key question are:

Safe - Good

Effective – Requires Improvement

Caring - Good

Responsive – Requires Improvement

Well-led - Good

Following our previous inspection on 11 September 2019, the practice was rated as requires improvement overall and for all key questions except safe which was rated as good. The September 2019 inspection was carried out following a period of special measures to ensure improvements had been made and to assess whether the practice could come out of special measures.

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 ‘shoulds’ identified in the previous inspection.

How we carried out the inspection

Throughout the COVID-19 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 and telephone calls.
  • 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.
  • Asking patients to submit online feedback.

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 and for all population groups.

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.
  • The practice identified and learnt from significant events. The learning was shared with all practice staff.
  • Risk assessments and mitigating actions had been put in place to protect patients and staff during the COVID-19 pandemic.

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

  • Improvements had been made to the practice’s performance on quality indicators. Although the steps taken to improve uptake for cervical screening was positive, the impact from this work was not fully effective and uptake for cervical screening remained below the 80% minimum target set by Public Health England.
  • Care plans for patients experiencing poor mental health did not contain sufficient detail. There was information regarding observations of the patients’ physical health such as weight and blood pressure recording but there were no details of their mental health care plan.

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

  • Feedback from patients was positive regarding the care they received.
  • Improvements had been made to patient satisfaction with a positive increase in results of the National GP Patient survey, published in July 2020.
  • The practice had identified more carers and improved the support offered to them.

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

  • Results from the National GP Patient survey published in July 2020, showed that patient satisfaction with access to the practice and appointment booking had declined. The practice had made some changes to improve patient satisfaction. However, the impact of these had not yet been assessed.
  • Improvements had been made to the handling of complaints.

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

  • The GP partnership had been strengthened with two new partners.
  • The practice had recruited an experienced practice manager.
  • They had made improvements to governance arrangements. Practice policies and procedures were followed.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • Feedback from patients at the time of the inspection was positive regarding improvements made by the practice.

The areas where the provider must make improvements are:

  • 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:

  • Continue to seek innovative ways to encourage eligible patients to have cervical cancer screening.
  • Continue to Improve the identification of patients who have caring responsibilities.
  • Take actions to improve the levels of patient satisfaction particularly in relation to telephone access and appointment booking.

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

11 September 2019

During a routine inspection

We undertook a comprehensive inspection of Lister House Surgery on 18 and 19 June 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The overall rating for the practice was inadequate and the practice was placed into special measures for a period of six months. We undertook a further announced comprehensive inspection of Lister House Surgery on 14 February 2019. This inspection was carried out following the period of special measures to see if improvements had been made and to assess whether the practice could come out of special measures. The practice continued to be rated as inadequate overall and remained in special measures for a further period of six months. The full comprehensive reports on the June 2018 and February 2019 inspections can be found by selecting the ‘all reports’ link for Lister House Surgery on our website at

At the time of the June 2018 inspection the practice was led by two GP partners. Since the inspection, one of the GP partners resigned and a new partnership of three GPs was formed as a new provider. The new provider name is Dr Ihonor and Partners and the location is now known as Lister House Surgery – Luton.

This announced comprehensive inspection on 11 September 2019 was carried out following the period of special measures to ensure improvements had been made and to assess whether the practice could come out of special measures.

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 and requires improvement for all population groups.

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

  • Systems and processes were in place to safeguard patients.
  • Staff had received the appropriate training for their role.
  • Risk assessments were in place to protect patients from harm.
  • The practice identified and learnt from significant events. The learning was shared with all practice staff.
  • Recruitment checks were carried out for all staff. We found a full immunisation status record had not been kept for two new employees. This was immediately rectified on the day of the inspection.
  • The practice carried out audits to ensure the patients who were prescribed high risk medicines had received appropriate blood monitoring. We found one patient had not received blood monitoring. The practice contacted the patient straight away to arrange for a blood test to be completed.

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

  • The practice’s performance on quality indicators for patients was below local and national averages in some areas.
  • Unverified data supplied by the practice demonstrated some improvement had been made in the practice’s performance on quality indicators for patients with long term conditions.
  • The practice had taken measures to increase the uptake of baby immunisations and cervical screening.
  • Clinical audits were undertaken to demonstrate quality improvement.

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

  • Some of the results of the National GP Patient survey had decreased from the previous year.
  • Less than 1% of patients had been identified as a carer.
  • Feedback from patients on the CQC comments cards, the practice’s own survey and the NHS Friends and Family Test was positive regarding the care received.

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

  • Complaints were not handled in line with the practice’s documented policy and recommended guidelines.
  • Improvements had been made to the practice that had resulted in an increase in patient satisfaction.

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

  • There were failings in some of the governance arrangements, specifically in relation to complaints management, recruitment procedures and high risk medicines monitoring.
  • Improvements had been made to the clinical and operational management within the practice.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

The areas where the provider should make improvements are:

  • Continue to take actions to improve the practice's performance on quality indicators.

  • Make improvements to cancer detection and screening rates.

  • Take actions to continue to improve the levels of patient satisfaction.

  • Improve the identification of patients who have caring responsibilities.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

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