The Care Quality Commission
  • Doctor
  • GP practice

Dr Avinash Suri Also known as Hainault Surgery

Overall: Good read more about inspection ratings

34 New North Road, Hainault, Ilford, Essex, IG6 2XG (020) 8501 3431

Provided and run by:
Dr Avinash Suri

All Inspections

21 and 26 June 2023

During a routine inspection

We carried out an announced focused inspection at Dr Avinash Suri (also known as Hainault Surgery on 21 and 26 June 2023. Overall, the practice is rated as Good.

Safe - Good

Effective – Requires improvement

Well-led – Good

Following our previous inspection on 2 and 8 August 2022, the practice was rated inadequate overall and for the above key questions. It was rated for Good for the Caring and Responsive key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Avinash Suri on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection on 21 and 26 June 2023 to follow up breaches of regulation from our previous inspection in line with our inspection priorities.

How we carried out the inspection/review

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We found that:

  • The practice had established systems and processes that kept patients safe and protected them from avoidable harm.
  • Patients received care and treatment that met their needs in a timely fashion.
  • The practice had implemented a programme of clinical and quality improvement audits.
  • Staff had the skills and knowledge to carry out their role effectively.
  • There was oversight and monitoring of the work of clinical staff working at the practice by the providers.
  • The practice had systems in place to manage and mitigate risk relating to the practice.
  • Systems and processes to learn and improve from incidents that occurred at the practice had been embedded.
  • The way the practice was led and managed promoted the delivery of person-centre care.
  • The providers had a suite of policies and procedures in place to assist in the governance of practice.
  • The practice now had a functioning patient participation group (PPG)

Whilst we found no breach of regulation, the provider should:

  • Make arrangements for a separate fire and infection prevention control risk assessments to be undertaken.
  • Continue with programme of increasing uptake of childhood vaccinations.
  • Maintain monitoring of all patients ongoing needs in accordance to national guidelines.
  • Continue with programme of increasing uptake of cervical screening.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

18 and 25 January 2023

During an inspection looking at part of the service

We carried out an announced unrated warning notice follow-up inspection at Dr Avinash Suri (also known as Hainault Surgery) on 18 and 25 January 2023. The practice was previously inspected on 2 and 9 August 2022, when we rated the practice as follows: -

Safe - Inadequate

Effective – Inadequate

Well-led – Inadequate

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Avinash Suri on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was to assure ourselves that the provider had complied with the warning notice issued as a result of the surgery being rated overall inadequate following our previous announced focused inspection of the surgery in August 2022.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We found that:

  • The practice had put in place a system to monitor patients on some high risk medications.
  • The practice had put in place a system to ensure that vaccines held at the practice were kept according to manufacturer’s guidance.
  • Clinical searches undertaken by the inspection team identified that not all patients were receiving appropriate clinical monitoring by way of medicines reviews.
  • Systems had been established at the practice to ensure that clinical staff were working within their scope of knowledge.
  • Clinical searches undertaken by the inspection team identified that not all patient records contained detailed information relating to face-to-face consultations.

We found one breach of regulations. The provider must:

  • Ensure that care and treatment is provided in a safe way.

The areas where the provider should make improvements are:

  • Continue with embedding operational processes within the practice to ensure the practice can operate safely.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

8 August 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at Dr Avinash Suri (also known as Hainault Surgery on 2nd and 8th of August 2022. Overall, the practice is rated as Inadequate.

Set out the ratings for each key question

Safe - Inadequate

Effective - Inadequate

Well-led - Inadequate

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Avinash Suri on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection to follow up on:

  • Information received regarding the provision of care at this location

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video and teleconferencing.
  • Completing remote clinical searches on the practice’s patient records system and discussing findings with the provider.
  • Reviewing patient records remotely to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • What we found when we inspected
  • Information from our ongoing monitoring of data about services and
  • Information from the provider, patients, the public and other organisations.

We have rated this practice as Inadequate overall

We found that:

  • The provider did not always provide care in a way that kept patients safe. This was highlighted by lack of monitoring of patients with long-term conditions and on high-risk medicines.
  • There was no oversight and monitoring of the work of clinical staff working at the practice.
  • Staff dealt with patients with kindness and respect and provided assistance when required, involving them in decisions about their care.
  • Staff were working outside of their terms of employment.
  • There was inconsistent monitoring of medicines and vaccines held at the practice.
  • The provider adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way. Additional services had commenced at the practice in response to patient demand.
  • The way the practice was led and managed did not always promote the delivery of person-centre care.
  • The provider had minimal policies and procedures in place to assist in the governance of practice.
  • There was little evidence that the provider had processes to manage risks, issues and performance.

We found two breaches of regulations. The provider must:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective care systems and process to ensure good governance in accordance with the fundamental standards of care.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for a key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

2 August 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Avinash Suri (also known as Hainault Surgery) on 10 May 2016. The overall rating for the practice was good, with the key question of ‘effective’ rated as requires improvement. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for Dr Avinash Suri on our website at www.cqc.org.uk.

This inspection was a focused follow up inspection carried out on 2 August 2017 to confirm that the practice had carried out improvements in relation to our previous inspection on 10 May 2016.

Overall the practice rating remains as good.

Our key findings were as follows:

  • Clinical audits were being used to drive improvement in performance to improve patient outcomes. The practice had completed one two-cycle audit since our last inspection.
  • Data from the Quality Outcomes Framework showed patient outcomes were at or above the national average, except for some indicators for diabetes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

10 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Avinash Suri on 10 May 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Although some audits had been carried out, we saw no evidence that audits were driving improvements to patient outcomes. There had been no completed audits carried out in the 12 months prior to our inspection.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Put systems in place so that an infection control audit of the practice takes place on an annual basis.

  • Strengthen the use of systems such as clinical audit to monitor quality and to make improvements.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

15 October 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Suri Avinash on 15 October 2015. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • Not all the shortfalls in staff training we identified at our last inspection of the practice in July 2014 had been addressed. Not all staff had received training on safeguarding vulnerable adults or refresher training on infection control, despite the provider sending us an action plan stating staff would complete training by November 2014. Other shortfalls we had identified in training for staff on health and safety at work and handling patient confidential information safely had been addressed.
  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Data showed patient outcomes were similar to national averages. We saw evidence that audits were driving improvement in performance to improve patient outcomes.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Urgent appointments were available on the day they were requested, and patients said they could get non-urgent appointments easily.
  • The practice had proactively sought feedback from patients.

The areas where the provider must make improvements are:

  • Ensure all staff that might be called upon to act as a chaperone have received a Disclosure and Barring Service (DBS) check.
  • Ensure the DBS check is completed satisfactorily before a new member of staff begins to treat patients or that provisions are made to safeguard patients when there is a delay in the DBS process.
  • Ensure information in relation to each person working for the service as specified in Schedule 3 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 is available for staff who joined the practice after 01 April 2013.
  • Ensure the action plan arising from the infection control audit in 2014 is completed.
  • Ensure a defibrillator is available or a risk assessment is completed and documented that indicates the practice does not need a defibrillator to mitigate risks to the safety of patients.
  • Ensure staff have the appropriate level of competence in safeguarding vulnerable adults, infection control and cardiopulmonary resuscitation (CPR).
  • Ensure systems and processes are established and operated effectively to support the Practice Manager in their role.

In addition the provider should:

  • Review and update where necessary its business continuity plan for major incidents and include within the plan arrangements to be put in place in the event of the GP having to take leave unexpectedly.
  • Make explicit to staff its policy on resourcing training to meet practice development needs and training, if any, to further an individual’s interests, ambitions and career development.

Where a practice is rated as inadequate for one of the five key questions or one of the six population groups it will be re-inspected within six months after the report is published. If, after re-inspection, it has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place it into special measures. Being placed into special measures represents a decision by CQC that a practice has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

23 July 2014

During an inspection in response to concerns

We were able to speak with a few patients, who were very complimentary about the service they received. One patient, for example, told us they were always seen quickly when they needed an appointment with the GP, and that their repeat prescriptions were delivered efficiently.

At least 70% of respondents to the practice's annual patient survey for 2013-14 rated the service as excellent in response to questions about ease of getting through to someone at the surgery, making appointments, and the effectiveness of the GP to meet their needs, for example.

Concerns had been expressed to the Care Quality Commission about staffing, treatment and care, infection control, and patients not being treated with respect. These concerns had triggered this inspection.

During the inspection we found patients' privacy and dignity were respected. Patients experienced treatment and care that met their needs and there were enough suitably qualified, skilled and experienced staff. However, there had been no formalised refresher training on health and safety at work, infection control, handling patient confidential information safely, or safeguarding vulnerable adults for staff to ensure their knowledge and skills were kept up-to-date. Patients were cared for in a clean, hygienic environment.