Alston Medical Practice

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 looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as Good. At this assessment, the rating has stayed the same.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them whether that was in person, over the phone or via other communication channels.

Feedback from people using the service was extremely positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs.

Reception staff were aware of the needs of the local community. They used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments. Staff checked people’s health, care, and wellbeing needs during health reviews. The provider had effective systems to identify people with previously undiagnosed conditions. Further evidence of the practices’ knowledge of the patient demographic and receptiveness to feedback was the introduction of an onsite physiotherapist run alongside a secondary care provider. This helped the practice to meet people’s assessed needs.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation. They worked to develop evidence-based good practice and standards.

We saw evidence of the practice putting in place tailored support for patients and their families when they were given a palliative diagnosis, working with district nurses and care home teams. Feedback from 6 families noted the “excellent holistic patient centred care” provided by the practice. The practice used 2 NHS funded beds that were commissioned in partnership with the local authorityin the local care home for palliative care and step-up/step-down care following any secondary care admissions.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. This included peer reviews, appraisals, regular clinical training reviews, time-out sessions, and access to training and development to enable staff to feel confident in their roles. For example, National Institutes of Clinical Excellence (NICE) guidance updates were shared, discussed in the practice meeting and implemented into practice. Changes made ensured steroid inhalers prescribed with salbutamol were reviewed by practice leaders to ensure compliance.

A remote review of the patient record system showed that patients received appropriate long-term condition reviews.

The provider demonstrated numerous audits that had been carried out following the 2-cycle method that had a clear positive impact on patients.

For example, the practice conducted annual audits of patients with prostate cancer who received Prostate-Specific Antigen (PSA) monitoring. This identified an incident where an abnormal PSA was incorrectly filed as normal. Clinicians did a prompt review of all patients with a diagnosis of prostate cancer to ensure that results could not have been incorrectly filed as normal. This resulted in an updated diary date recall to specify what PSA should be and the threshold for re-referral. Staff were reminded of the importance of checking PSA levels against previous tests. On the back of this work, an enhanced protocol for patients who request a PSA test had been put in place. This protocol was shared with linked practices as an example of good clinical practice. The patient information leaflet was also reviewed and amended with links to a more in-depth video about PSA and prostate cancer. Patient numbers effected by this audit were 23 in 2024-2025 and 24 in 2025-2026. This exercise has resulted in appointments being offered to patients and discussions being held to ensure the most appropriate course of action is undertaken for each patient.

The service worked well across teams and services to support people. For example, they shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

The practice held regular Multi-Disciplinary Team meetings where clinicians and others would discuss vulnerable patients, share examples of good practice and provide support to one another if it was required. There was also a clinical leads meeting held with other practices in the Cumbria Health group where good practice was shared and discussed. Clinicians at Alston shared with colleagues their work on prostate cancer patients and weight loss drug protocols.

Following the closure of the community hospital in 2017 it was agreed there would be 2 NHS funded beds available at the local care home. The beds were available for step-up care to prevent a hospital admission, step-down care from hospital and also for end-of-life care. This led to a reduction in hospital admissions for numerous patients. Collaborative working with the district nurses enabled this service to run effectively and improved patient care. It has also been used for patients nearing the end of life, allowing them to stay locally. The practice worked collaboratively with the district nursing team, the local county council and adult social care to maintain these beds to ensure that patients within them had access to prompt clinically safe and effective care and treatment which was joined up and met their needs.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. The practice held palliative care meetings regularly where clinicians could discuss patients’ needs with district nursing teams and put appropriate support in place for them and their families. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The practice utilised the patient participation group (PPG). The PPG told us when issues or suggestions were brought to the practice they were listened to and resolved promptly. For example, the car parking situation at the practice – spaces were limited and roads leading up to the practice could be difficult in adverse weather. This had been a standing item on PPG meeting agenda, and the practice leadership continued to engage constructively with the local authority to try and address issues.

The practice, given its rural nature and being aware of its patient demographics, identified gaps in targeting loneliness and the potential for self-neglect and had set up a hub for people to access. The ‘social day unit’ was a recognised community resource that practice leaders and staff took pride in.

The service monitored all people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves.

The practice met national targets for cervical smears. For women under 49 the practice had achieved 82% coverage against a target of 80%. For women over 50, the practice had achieved 81% coverage against a target of 80%. Furthermore, childhood immunisations were all achieving target at the time of our site visit.

There was active engagement in activities to monitor and improve quality and outcomes. Clinicians were enthusiastic about quality improvement and strived to ensure all patients received the best outcomes. We reviewed audits which clearly demonstrated improvement for patients. This included patients on Direct Oral Anticoagulant (DOACs), used to prevent blood clots, looking at the holistic processes set by the practice including weight checks and routine blood tests. This process also enhanced collaboration with clinicians in secondary care settings. The review found this process and the recall system used at the practice (patients were reviewed every 6 months) was working effectively but it would be continuously reviewed going forward. The reviews have resulted in enhanced clinical reviews looking at reducing the risk of Gastrointestinal (GI) bleeding. EMIS clinical systems have been developed to include additional safety nets when running searches.

The number of patients that have benefited from this continuously developing review programme has increased; from 12 patients being identified in 2018 to 71 patients in 2025 when the most recently completed audits had been carried out.

The practice undertook reviews of non-medical prescribers’ (NMP) consultations which looked at the prescribing of antibiotics and controlled drugs. The review involved discussions with the NMP and resulted in audits being done on certain processes in the practice including gabapentin and pregabalin. There were no major concerns following this audit, with no themes identified or areas of concern. The reviews were welcomed by staff and allowed for further team integration and sharing of quality patient care. The positive work that NMPs were doing in the practice can be highlighted by the number of patients who were being issued prescriptions for certain medicines. For example, in 2021/2022 119 patients were being prescribed dihydrocodeine (for pain relief) whilst in 2025/2026 only 10 patients were issued a prescription. For gabapentin (which is prescribed for pain relief and epilepsy), figures we saw showed 50 patients needed this medication in 2020/21 whilst only 27 needed it in 2025/26. The practice had also been able to significantly reduce the number of high dose opiate prescriptions issued through the hard work of prescribing pharmacists.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.