Abbey Meads Medical Group

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.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

This service scored 83 (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.

People gave positive feedback about the service. They felt involved in assessments of their needs and were confident staff understood their individual and cultural requirements. In the 2026 GP Patient Survey, 98% of respondents said the healthcare professional had the information needed about them, which was above the national average of 93%.

The service could access translation services for people who needed them. Staff used digital flags in care records to highlight individual needs, such as the need for an interpreter. Record alerts also identified when people needed longer appointments, including people whose first language was not English and people with a learning disability.

People with a learning disability were clearly identified on the clinical system and proactively invited for annual health checks. These reviews helped monitor their wellbeing and identify health needs early. Structured templates supported consistent and comprehensive care.

Staff reviewed people’s health, care and wellbeing needs during health reviews. Most people, 89%, said their needs were met at their last appointment, which was also reflected in feedback sent to CQC.

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 and current evidence-based good practice and standards.

The service had effective systems to ensure staff remained up to date with evidence-based guidance and legislation Clinical meetings were used to share best practice updates and review care to ensure treatment decisions reflected current evidence-based guidance. The service carried out structured annual reviews for people with long-term conditions, including heart failure, diabetes, chronic kidney disease, osteoporosis and obesity. Reviews included follow-up of people who did not attend, validation of disease registers, reviewing information from secondary care services and assessment of ongoing care and treatment remained consistent with current evidence-based practice.

Regular Gold Standard Framework meetings were held with external partners, including hospice services, to review people receiving palliative or end-of-life care, agree actions and support coordinated care.

Clinical searches showed people’s care and reviews were completed in line with national guidance. Staff used recognised evidence-based tools to support long-term condition management, and review processes were monitored to ensure they were timely, structured and responsive to people’s needs.

The service demonstrated a consistent approach to monitoring and managing long-term conditions, ensuring care and treatment decision were informed by current evidence and best practice guidance.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff had access to the information they needed to assess, plan and deliver people’s care, treatment and support. The service worked with external partners, including community services, to develop and implement care plans that supported safe and effective care for vulnerable people.

Staff worked closely with community nursing, hospice and other healthcare teams, using clinical and integrated care records to share information and support continuity of care.

Our remote review of clinical records showed effective processes to support safe and coordinated transitions between services. Referrals and discharge summaries were managed appropriately and reflected people’s individual needs and ongoing care requirements. Shared care records were used where required, and relevant information, including records care plans and resuscitation decisions, was available to authorised healthcare professionals involved in people’s care.

The service worked with other providers to maintain continuity of care where clinical tasks were shared or delegated. Enhanced access arrangements with the GP federation enabled people to book appointments outside core opening hours, including Saturday clinics.

Enhanced access clinics and online consultations followed the service’s existing care pathways and were integrated with the clinical system. This meant that, with appropriate consent, information and medical records could be shared between providers, supporting continuity of care and coordinated care delivery.

The service offered an NHS-approved online consultation platform, which allowed people to book and attend video consultations during extended hours on weekdays and at weekends. These arrangements gave people more flexible access to healthcare, including those unable to attend during standard hours.

The service always supported people to manage their health and wellbeing to fully 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.

The service demonstrated a proactive and systematic approach to helping people live healthier lives. Staff used clinical records, population health information and routine contacts with people to identify those who may be at increased risk of poor health outcomes. This included people in the last 12 months of life, people at risk of developing long-term conditions, people with caring responsibilities, and people who may benefit from earlier intervention or additional support. The service used this information to offer targeted advice, recalls and health checks, including NHS health checks, to support prevention, early identification of health concerns and healthier lifestyle choices.

Health promotion was embedded into day-to-day practice and aligned with national priorities and local population need. Staff supported people with smoking cessation, weight management and wider wellbeing needs, including through access to an in-house health and wellbeing coach. The service used information boards, its website and routine clinical contacts to promote relevant health campaigns and encourage uptake of preventative care, for example cervical screening awareness. Information was updated regularly so that people received timely, relevant and accessible advice.

The service recognised that people’s health and wellbeing could be affected by social, practical and emotional factors as well as clinical need. Staff identified people who required additional support and referred them to appropriate services, including social prescribing. This enabled people to access community-based, non-medical support for issues such as social isolation, housing concerns, limited support networks and wider wellbeing needs. This showed a person-centred approach to prevention and reducing the risk of deterioration.

The service had effective arrangements to identify and support carers. Carers were recorded on clinical systems and offered tailored support, including health checks, flu vaccinations, coffee mornings and information through the service website. The service also organised a local carers’ roadshow involving charities and specialist organisations. Feedback from people who attended was positive, which demonstrated that the service was engaging with carers and using local partnerships to improve access to support.

The service used quality improvement activity to address identified risks and improve outcomes for people. Following a review of prescribing data, clinicians completed an opioid prescribing audit and introduced a range of actions to support safer, evidence-based pain management. These included clinician and GP trainee training, updated prescribing guidance, increased use of non-opioid and self-management approaches, and referrals to the First Contact Practitioner service for people with musculoskeletal pain. This resulted in opioid prescribing reducing from 14.7 to 13.7 prescriptions per 1,000 people, with prescribing remaining below local and ICB averages. Staff were also able to describe examples where people had reduced or stopped strong pain medicines and managed their symptoms through less intensive, safer approaches. This demonstrated that improvement activity was targeted, monitored and linked to measurable benefits for people.

The service also implemented a targeted cervical screening improvement programme. This included personalised recalls, flexible appointments, opportunistic promotion during routine appointments and wider health promotion activity. These actions were designed to improve screening uptake, reduce health inequalities and support earlier identification of cervical abnormalities. The approach showed that leaders and staff were using targeted activity to improve prevention and support better long-term health outcomes for people.

The cervical screening improvement plan strengthened the practice’s use of data through monthly monitoring of screening coverage, overdue people, recall responses, appointment utilisation and DNA rates, enabling targeted interventions for patients least likely to engage with screening. Baseline uptake was 59% for people aged 25–49 years and 73% for people aged 50–64 years, highlighting the need for focused improvement activity. Targeted SMS reminders, telephone follow-up, opportunistic booking and flexible appointment availability increased opportunities for patients to access screening and helped address barriers to attendance. These actions improved access to preventative healthcare, increased awareness of the importance of screening and supported earlier identification of cervical abnormalities. Ongoing monitoring will allow the service to measure improvements in uptake against the baseline figures and assess progress towards the national target of 80%.

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 pharmacy and clinical teams regularly reviewed data relating to long-term conditions and medicines safety, including cholesterol, heart failure, hypertension, stroke and diabetes. Where gaps in care were identified, staff reviewed records, contacted people for checks, arranged pharmacist reviews and updated records to ensure people received timely, evidence-based follow-up.

The service demonstrated clear impact from this approach. For example, monitoring of people prescribed higher-risk blood-thinning medicines improved significantly after the service identified overdue blood tests and introduced targeted follow-up. The number of people overdue monitoring reduced from 84 to 37 in January 2026 and to 6 by February 2026. This demonstrated how the service used data to identify risk, take prompt action and improve safety outcomes.

The service used audits and structured medicine reviews to improve the quality and safety of care. One audit focused on people prescribed medicines for nerve pain alongside opioids or sleeping tablets, as these combinations can increase the risk of side effects such as drowsiness, breathing problems and dependence. All 10 people identified received a comprehensive medicines review and advice about their treatment. Following review, 1 person had their opioid dose reduced, 1 person stopped taking an opioid and 1 person stopped gabapentin (used for nerve related pain) because the risks outweighed the benefits. This reduced the risk of medicine-related harm and improved people’s understanding of their medicines.

Learning from the audit resulted in clearer action planning, routine review of pain medicines during each contact and regular monitoring for people prescribed pregabalin who may become pregnant. This provided assurance that improvement activity was embedded, sustained and focused on people most at risk.

The service also adopted a structured population health approach to improving vaccination and immunisation uptake. Monthly searches identified people with missed or incomplete vaccinations, and staff followed these up through text messages, email, letters, telephone calls and additional reminders where appointments were not booked. Staff identified barriers to uptake, including access difficulties, vaccine hesitancy and language needs, and responded with extended access appointments, drop-in clinics, opportunistic vaccination during routine appointments, translated information and supportive discussions with a clinician. Population health data was used to identify groups with lower uptake, and the service worked with partners including schools, health visitors, maternity services, public health teams and Child Health Information Services to improve coverage and reduce health inequalities.

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

Staff understood and applied legislation and guidance relating to consent. Consent for care and treatment was obtained verbally or in writing, as appropriate, and clearly documented in clinical records. Staff demonstrated a good understanding of consent processes and ensured people were informed and involved in decisions about their care and treatment. Relevant staff had completed Mental Capacity Act training and clinical staff understood how to apply the legislation and guidance when assessing capacity and making consent related decisions.

Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were made appropriately and in line with relevant legislation and guidance. Records showed DNACPR forms were completed, reviewed and shared with relevant services where appropriate, and alerts were added to people’s records to support continuity of care. Where people lacked capacity, records included appropriate documentation to demonstrate decisions had been made in accordance with legal requirements.