Ambrose Avenue Group 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.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We found the practice made sure people’s care and treatment was effective by monitoring and reviewing their health, care, wellbeing, and communication needs with them.

Feedback from people using the service said they felt involved in their care and treatment and were confident that staff understood their individual needs. Feedback from care home representatives were positive about the practice services provided to their residents.

Reception staff used digital flags within the care records system to highlight any specific individual needs, such as their requirement for a longer appointment or a translator to be present for appointments. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. (A social prescriber isa healthcare professional who connects patients with non-medical, community-based services to address social, emotional, and practical issues affecting their health).

The practice planned and delivered people’s care and treatment with them, including what was important and mattered to them. We saw they did this in line with legislation and current evidence-based good practice and standards.

Systems and regular training sessions were in place to ensure staff were up to date with evidence-based guidance and legislation. We found people’s clinical records demonstrated care was provided in line with the current guidance.

We saw the practice staff worked well across teams and services to support people. They shared the assessment 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.

Arrangements were in place for practice teams to support each other during periods of staff sickness, annual leave, and busy periods of the day within the practice. For example, staff were trained to support receptionists at times of peak telephone demand.

The practice supported people to live healthier lives and where possible, reduce their future need for treatment and support. People were supported to manage their health and wellbeing to maximise their independence, choice, and control.

People who provided feedback had no concerns in this area. Representatives from care homes told us people in their care received general and specific health checks for example, preventative vaccinations.

The practice was on track to achieve their target for NHS health checks offered to people aged 40 to 74 years. Healthy living information was available in the waiting room, around the practice and on the practice website. There was a well-placed information board in the waiting room that provided information about health and social services available to the local population.

Clinical staff described how they supported national priorities and initiatives to improve population health, this included stopping smoking and tackling obesity. Staff could refer people with social needs. Staff identified risks to peoples’ health, including people at risk of developing a long-term condition, those with caring responsibilities and people in the last 12 months of their lives.

The practice routinely monitored people’s care and treatment continuously, for positive, consistent patient outcomes, which met both clinical and people’s expectations.

Practice staff had worked to improve the uptake of childhood immunisation. All 4 indicators met the minimum expectation of 90% and one indicator had met the World Health Organisation (WHO) target of 95%.

The nursing team were working towards improving their cervical screening recall system as they had missed the 2 targets of 80% achieving 76.1% and 78.8% in the most recently published 2024 data available. Arrangements were in place to follow up with people when they did not respond to an invitation or attend their appointment.

The practice told people about their rights to consent, and respected peoples’ wishes when delivering person-centred care and treatment. Feedback provided by people we spoke with told us they felt at ease during consultations, were listened to, procedures were explained, and consent was requested.

Clinicians told us they supported people to make decisions, and where appropriate, assessed, and recorded people’s mental capacity and decisions as part of the consent process. Clinicians told us they always obtained consent from people and offered a chaperone where appropriate, which was recorded on the clinical system. We saw posters attached to treatment room doors to remind people they could request a chaperone.

Staff who carried out chaperone duties were trained for the role and had received an appropriate disclosure and barring (DBS) check.

Capacity and consent were recorded in peoples’ records. Care homes confirmed do not attempt cardiopulmonary resuscitation (DNACPR) decisions and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms were appropriate and were made in line with the relevant legislation.