Avon Road Surgery

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 with advice and support and staff regularly reviewed people’s care and worked with other practices 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.

Clinical staff assessed patients’ health care needs. Patients with long-term conditions received structured annual reviews to ensure their health and medication needs were met. Robust systems were in place to identify undiagnosed conditions. For those with complex needs, GPs worked with other professionals to provide coordinated care. All patients who presented with urgent needs, were triaged by a clinician to provide early assessment for exacerbations and to help prevent admission to secondary care. The national GP survey found 88% of respondents said their needs were met.

The practice used a computer software system to support the delivery of evidence-based care, it had integrated national guidance and local medicine optimisation pathways and supported the ICS medicines strategy. Patients’ needs were assessed, and care was delivered in line with legislation, clinical standards, and evidence-based guidance, supported by pathways and tools. Systems ensured staff remained up to date with guidance, and the clinical records reviewed showed care was delivered in accordance with best practice. The practice took part in local incentive schemes for chronic obstructive pulmonary disease, asthma, and diabetes to improve patients’ health outcomes. The practice used computer software to ensure patients were recalled for their annual health reviews.

Avon Road Surgery had created and implemented a structured post asthma exacerbation follow-up and monitoring process in line with NICE guidance. This ensured that all patients who had experienced an asthma exacerbation who have been prescribed oral steroids and/or antibiotics receive a proactive clinical follow-up within 48 hours to assess treatment response, safety, and ongoing management needs.

The staff worked collaboratively across NHS teams and services to help ensure seamless care. Staff met with the safeguarding, and multi-disciplinary teams regularly. Assessments were shared when patients moved between services. Staff had timely access to the information needed to assess, plan, and deliver care effectively. The practice worked closely with partner services to maintain continuity of care.

Staff supported people to manage their health and wellbeing. They focused on prevention and early intervention to help reduce future care needs. Staff identified health risks such as end-of-life needs, frailty, carer responsibilities and supported national health priorities, including smoking cessation and obesity reduction.

The practice had a comprehensive programme of quality improvement activity and reviewed the effectiveness and appropriateness of the care provided. These included minor surgery audits, sick day rules advice for patients with diabetes, timeliness and safety netting in response to raised faecal immunochemical tests, reducing harm from valproate in males and females. The staff monitored people’s care and treatment to improve it.

The practice achieved over the 95% national target for the administration of childhood immunisations in 2023/24 in three areas and 89% in one area. In addition, the uptake of cervical screen in 2023/24 was approximately 80% which met the national target. The practice also provided unverified data to demonstrate the national targets would be met for 25/26.

Staff 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.