Dalston Medical Group

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• 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 monitored people’s care and treatment and supported them to live healthier lives. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

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 did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

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

Staff focussed on identifying risks to people’s health, including those in the last 12 months of their lives and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

Staff were able to support people with their health and wellbeing through a range of social prescribing initiatives, including support for those experiencing social isolation, housing difficulties, and wider wellbeing concerns. The primary social prescribing pathway was to a dedicated social prescriber working with children and young people across the Primary Care Network (PCN). In the previous 12 months, staff had made 8 direct referrals, although the provider also worked closely with local schools to identify and support children and young people who may benefit from additional assistance.

The practice also worked closely with the adult wellbeing service, which included wellbeing coaches funded through the PCN and Integrated Care Community (ICC). During the previous 12 months, the practice made 78 referrals, primarily for patients identified as being at risk of developing diabetes.

An additional service delivered through the PCN and ICC was led primarily by occupational therapists. Staff used a recognised and evidence-based clinical measure of frailty to proactively identify patients living with frailty and provide appropriate support. Between 1 September 2025 and 9 January 2026, 255 patients were referred to the service. All referred patients were contacted, and 42 subsequently engaged with the support offered.

The practice routinely monitored people’s care and treatment to continuously improve it. They ensured outcomes were positive, consistent and met the expectations of people themselves.

The practice exceeded 4 national targets for the uptake of childhood immunisations with 4 of the indicators at 100% against an expected level of 95%. There was 1 indicator slightly below the expected national level of 95% at 93% for the practice. This was for children aged 5 who have received immunisation for measles, mumps and rubella (2 doses of MMR).

The practice met or exceeded the England average performance in relation to cancer screening programmes, including screening for breast, bowel and cervical cancer.

We saw there were 14 patients aged 14 years and over with a learning disability registered at the practice. Staff had completed 11 annual learning disability reviews, representing 79% of the eligible patients. All patients had been invited to attend for a review.

A designated administrator had coordinated annual learning disability reviews for the previous 2 years, including arranging appointments with patients and, where appropriate, their carers. Patients were offered extended appointments, consisting of an initial consultation with a designated healthcare assistant followed by a GP appointment to complete the review.

Staff told us this approach had improved engagement with the annual review programme and enabled them to develop a better understanding of individual needs. This supported the identification and implementation of reasonable adjustments to improve access to care, including offering home visits where appropriate to encourage attendance and participation in the review process.

Clinical audit and quality improvement were in place and used to review care and drive improvements in patient outcomes. Audit activity covered a range of areas, including medicines safety and long-term condition management. Prescribing audits formed part of this programme, helping to identify prescribing risks, improve prescribing practice and support patient safety and care.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.