Avon Road Surgery

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that the practice met people’s needs, and that staff treated people equally and without discrimination.

This service scored 89 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice ensured people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs. For example, the practice had initiated proactive identification of carers, gathering information about their caring roles and their emotional wellbeing to enable staff to provide tailored treatment, care and information for their needs. The project identified 57 new carers and 25 were referred to social prescribing for additional support. The practice had invited feedback from these patients which was positive, some stating they now know where to turn for information and support. The project enabled the practice to routinely improve the identification of carers during registration.

Patients feedback demonstrated they understood their options for care, support and treatment and were able to make informed choices and decisions. Care plans addressed patients’ physical, mental, and social needs, including those linked to protected characteristics. Clinical records showed patients were supported to understand their condition and actively involved in planning and decision-making about their care. The practice used a computer software tool to enable them to accurately monitor the local population health data, including age distribution, prevalence of chronic conditions, and social determinants of health (e.g. housing, employment, ethnicity).

For people with a learning disability or autism, the practice completed annual health checks and passports, to ensure information was available to health care professionals to enable continuity of care. Staff had completed Oliver McGowan training on learning disabilities and autism.

The practice was in the process of becoming a C-Card distributor. The C-Card scheme is a nationally recognised sexual health initiative providing free condoms and sexual health information, primarily to young people aged 13–24, and other individuals at increased risk of sexually transmitted infections or unplanned pregnancy. The practice was the only local service to provide this, and had set objectives of improving access, addressing health inequalities, promoting safe sex and early intervention.

The service had ensured they understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity. The practice had tailored its practices to meet the diverse needs of its community, for example, older people, frailty, carers and long-term health conditions.

For example, the practice was approached to participate in and lead a pilot of the Havering Child Health Hub Multi-Disciplinary Team (MDT) model within the local PCN. In response, Avon Road Surgery took an active leadership role, leading and chairing the MDT meetings to support timely, joined-up decision-making and personalised, child-centred care.

Avon Road Surgery is part of an established monthly frailty MDT across local PCN practices, providing routine access to a consultant geriatrician for complex, frail, and high‑risk patients. The MDT enabled structured case discussion, management of diagnostic uncertainty, and agreement of personalised, proactive care plans, delivering expert‑led, coordinated care closer to home, optimised medicines management, and reduced hospital admissions. The MDT meetings also informed NHS 111 and London Ambulance service contacts that enabled patients to be safely managed in the community.

The practice had implemented an age-based hospital discharge pathway for patients 65 years and over. Patients were shared with the primary care network aligned community team for frail older adults and their carers team. The team offered a comprehensive geriatric assessment, structured medication review, advanced care planning, universal care plan, which prevented readmission and deterioration. Following the launch 784 patients have received a comprehensive geriatric assessment, and between August 2024 and September 2025, 292 onward referrals were made, falls services, integrated therapy teams and occupational therapy.

A continuity of care model was implemented using a RAG-rated approach to prioritise patients with the highest clinical need. Frail and complex patients were identified and allocated a named clinician, ensuring consistent, personalised care and supporting continuity, trust, and safer clinical decision-making. The model was shared, rolled out, and embedded across the PCN, reducing the need for patients to repeatedly recount their history and enabling clinicians to develop a deeper understanding of individual needs and preferences.

During 2025, the practice conducted a high-intensity patient project to improve care for individuals who frequently used primary and wider health services, often due to complex, unmet needs. This involved three monthly multi-disciplinary team meetings including both clinical and non-clinical team members. The outcomes showed patients satisfaction was excellent, and they no longer frequently used the services, the workforce reported improved confidence when supporting patients with complex needs. The model was adapted throughout the local primary care network, and it helped to initiate and operationalise the continuity of care model.

The practice provided support for four care homes. Overall, the home staff reported an elevated level of satisfaction with the quality of care provided by the practice, and further access to face to face consultations.

For people with a learning disability or autism, the practice completed annual health checks and passports, to ensure information was available to health care professionals to enable continuity of care.

The practice provided accurate, up-to-date information tailored to individual needs, including materials in multiple languages to support screening and immunisation uptake. Interpreter practices, including British Sign Language, were available. Information met the Accessible Information Standard, and patients were informed about how to access their care records.

Following patient feedback, the practice implemented a quality improvement initiative to support patients in using the NHS App. This included a dedicated digital teaching session and a drop-in event in partnership with Age UK in September 2025, which 6 patients attended. Where staff guided patients through downloading, setting up, and accessing their records. The outcome was positive, and the practice now ranks among the largest locally for NHS App uptake.

The practice had developed and implemented a learning disability passport to support personalised, accessible, and responsive care. The passport is offered to all patients as part of their annual learning disability health check and captures key information including communication preferences, sensory needs, reasonable adjustments, anxiety triggers, reassurance strategies, and what matters most to the patient. It is a living document, reviewed and updated to reflect changing needs. The project has been recognised by the local PCN and secondary care.

The national patient survey for 2025 found 81% of patients found it easy using the practice website. Feedback from patients demonstrated 96% were aware of what the next step would be within 2 days of contacting the practice.

The practice used a computer software system to enable them to record and audit complaints. Staff encouraged people to share feedback, ideas, and complaints and communicated changes made as a result. Complaints were handled in line with policy, and staff could demonstrate learning and improvements based on patient feedback. Complaints were discussed at team and clinical meetings.

The 2025 National patient survey feedback was positive. For example: -

• 78% stated the overall experience of contacting the practice was good,
• 90% stated it was easy to contact the practice on the phone,
• 81% stated it was easy to contact the practice using their website,
• 91% stated the reception and administration team were helpful.

The practice operated an access model with four principles, directing patients to the right person, ensuring care was provided in a suitable setting, responding promptly to medical queries and ensuring a fair and non-discriminatory access. The leaders monitored and bench marked their uptake of appointments. For example for November 2025, 1,991 appointments were available and 1,615 were utilised, the provider explained the extra capacity was included to enable the staff to cover safeguarding concerns and urgent patient presentations.

Receptionists navigated patients to the appropriate service, all urgent cases were priorities and triaged by a clinician on the day of request to ensure patients were seen in priority of risk to prevent admission to secondary care. Older people were offered a wide range of methods of access, such as proxy for carers. Frail and complex patients were allocated a named clinician. All patients who were unable to leave their homes due to ill health were offered annual reviews. Children under 5 years were prioritised for rapid clinical review. Patients had access to an enhanced access service from 6.30 pm to 10 pm weekdays and all day at weekends.

Leaders monitored the practices community population and worked and collaborated with local organisations to tackle health inequalities in the local population. The provider had systems to continually review appointment availability (face-to-face, telephone, and online), interpreter services, and safeguarding measures to ensure all patient groups could access care.

The staff with the help of the patient participation group had carried out a patient survey during the covid and flu clinic held on Saturday 4 October 2025, where most of the patients were over 65 years. Survey results showed: 99% of patients rated their overall appointment experience as positive or acceptable, 98% found staff friendly, 87% felt waiting times were reasonable, and 99% felt listened to. In response, the practice will publish details of its appointment system to ensure patients know they can book by phone and that appointments remain accessible to meet individual needs.

People were given support to plan for important life changes, so they could make informed decisions about their future, including at the end of their life.

For example, the practice followed the Gold Standard Framework (GSF) for palliative care. The framework supported high-quality, coordinated, and person-centred care, ensuring patients were recognised early, had their preferences recorded, and received timely multidisciplinary support. The lead clinicians had completed the GSF training and updates. The practice maintained a live palliative care register within the clinical system and used colour coding to identify days to prognosis. This was visible to external agencies as updated in the Universal Care Plan (UCP). Monthly Multidisciplinary Team meeting was held with the community team to ensure the patients’ needs were met. Staff supported individuals to express and revise decisions about resuscitation.

The practice had developed and implemented a learning disability passport to support personalised, accessible, and responsive care. This captured communication preferences, sensory needs, reasonable adjustments, anxiety triggers, reassurance strategies, and what matters most to the patient. It was a living document, reviewed and updated to reflect changing needs.

The provider had processes in place for handling new patient information and met with other agencies and completed shared universal care plans and shared care agreements to enable the delivery of care when patients moved or were treated by different services.