Brinsley Avenue 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.

At our last assessment, we rated this key question as outstanding. At this assessment, the rating has changed to Good.

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.

The service mostly 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. Data from the National GP patient survey showed that 92% of respondents stated that during their last appointment they were involved as much as they wanted to be in decisions about their care and treatment. This was comparable with the national average of 91%.

Reception staff were aware of the needs of the local community. 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.

Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. For example, for people with a learning disability or people with long-term conditions. We found that people with asthma, diabetes and chronic kidney disease were reviewed appropriately. However, people with hypothyroidism were not always up to date with blood test monitoring. Following our assessment, the provider sent us evidence of the actions they were taking to address this.

The practice had worked alongside a pharmaceutical company to identify people with chromic pulmonary obstructive disease (COPD) who were not under the care of secondary care. They aimed to support this group of people to live well over the winter period and reduce hospital admissions. They obtained funding for a respiratory consultant to work with the practice to review this group of people. Clinicians shadowed the consultant for learning opportunities and as a result, implemented a spirometry service within the practice which they later rolled out to other practices within the Primary Care Network.

The practice had participated in a 3-part research project for chronic kidney disease. It included lifestyle advice, blood pressure monitoring and the development of a protocol to improve health outcomes for people. They presented their findings at a national conference during UK Kidney week 2026 to influence patient care on a national basis. For example, how to improve early diagnosis, coding and detection of disease progression. They had developed posters to promote this work.

The provider had systems to identify people with previously undiagnosed conditions. For example, the practice provided a 3-session service for people with pre-diabetes to provide health and lifestyle advice. The practice had also taken part in the use of smartphone cameras to detect potential patients with the heart rhythm disorder, atrial fibrillation. However, our remote searches identified 9 people with a potential missed diagnosis of diabetes which needed to be reviewed. Following our assessment, the provider sent us evidence of the action they had taken to review these people and any changes that were required.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

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.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was provided in line with current guidance.

The service worked well across teams and services to support people. They worked with the wider multi-disciplinary team to support people near the end of their life. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services. They worked closely with the Primary Care Network (PCN) and shared their services with other practices. For example, spirometry for people with respiratory disease.

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.

Staff were very positive about how the different staff groups worked together within the practice and told us there was a supportive culture across the whole team. They told us they felt supported by leaders to carry out their role.

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. The practice held group consultations for people with pre-diabetes. For example, diet and lifestyle advice. This was followed up with an assessment with a health and wellbeing coach who set individual goals. The lifestyle coach later reviewed these goals with people to assess their progress.

Staff focused on identifying risks to people’s 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 service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The practice mostly met national targets for screening and immunisations.

Indictors for childhood immunisation uptake for April 2024 to March 2025 showed that 2 out of the 5 indicators had met the 95% WHO base target. However, the 3 indicators for 2-year-olds were slightly below the 90% minimum target. They explained this was due to a delay in submitting their immunisation uptake to the UK Health Security Agency. The practice shared unverified data with us which showed their current uptake rates for these immunisations had increased to 90%.

The number of women aged 25 to 49 years old who had received an adequate cervical screening test was 79% and 78% for people aged 50 to 64 years old. These were slightly below the national target of 80%. The service had systems in place to follow up this group of people. For example, opportunistic screening, alerts of patients’ records and reassurance people could bring someone with them for support if they wished to do so.

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