The Avenues Medical Centre

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

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people to make decisions in people’s best interests where they did not have capacity.

This service scored 67 (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.

Feedback from people using the service was 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. Results from the National GP Patient survey showed that 96% of patients knew what the next step would be within two days of contacting the GP practice. The local and national average was 93%.

Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff checked people’s health, care, and wellbeing needs during health reviews.

We carried out a series of clinical searches to assess monitoring and quality of care for certain long-term conditions. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had effective systems to identify people with previously undiagnosed conditions. Searches identified potentially 64 patients with a missed diagnosis of CKD 3 – 5, a review of 5 patient records showed that 4 had been coded correctly. One patient was identified as having a missed diagnosis, this was immediately addressed by the practice.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. Through a service ran through the PCN, patients could be referred to an art therapist who helped with low level mental health concerns, this was particularly popular with younger patients.

The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them. We carried out a series of clinical searches to assess the monitoring for certain long-term conditions. Clinical records we saw demonstrated care was not always provided in line with current guidance.

Searches identified 16 patients with asthma who had been prescribed 2 or more courses of rescues steroids. A review of 5 patient records showed that 4 patients had not been followed up within the appropriate timeframe, as per NICE guidelines. When this was fed back to the provider the patients were immediately followed up. The provider also provided evidence to show that new processes had been implemented to ensure asthma patients would be followed up within the correct timeframes.

A review of clinical records identified potentially 8 patients from 245 with hypothyroidism which had not received the required monitoring. A review of 5 patient records showed that 3 were overdue monitoring, this was immediately actioned by the practice.

Systems and processes in place were working to identify patients with CKD level 4 or 5, and patients with diabetes with a HbA1c greater than 75 to ensure they received the required monitoring.

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 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 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. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The practice had a dedicated member of staff who was their “reasonable adjustments lead”. This was used to support patients who required additional help such as easy read materials.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The national target for routine childhood vaccinations is 90%. The World Health Organisation (WHO) recommends a rate of 95% for all routine childhood vaccinations. The latest data available to CQC (2024 – 2025) showed that the practice had not met the national target of 90% in 2 out of the 5 routine childhood vaccination age groups. They had achieved over 90% in the other 3 indicators but they had not met the 95% WHO recommended threshold.

The national target for cervical screening coverage is 80%. The most recent data (2024) showed that practice had achieved 71.2% for eligible patients aged 25 to 49 years old, and 77.4% for eligible patients aged 50 to 64 years old.

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.