Hazeldene Medical Centre

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• 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.

This is the first inspection for this service since its new registration with CQC in July 2025. This key question has been rated as Good.

This service scored 71 (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.

Reception staff were aware of the needs of the local community. Reception staff across all sites 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. The provider had effective systems to identify people with previously undiagnosed conditions. For example, during our remote clinical searches, we noted people were being appropriately coded as having diabetes or prediabetes following a review of their blood test results.

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. Regular clinical updates were shared with all clinicians via email and a dedicated Teams channel, with content developed by lead GPs. External speakers were also invited to deliver educational sessions to GPs on updated clinical guidance, supporting ongoing learning and best practice. Clinical records we saw demonstrated care was provided in line with current guidance.

Clinical audits undertaken by the service led to several quality improvements. For example, training and system changes were implemented to improve Vitamin B12 prescribing, with catch-up clinics established to review affected people. Following a review of cancer diagnoses and deaths, new software was embedded into clinical pathways, alongside the development of a more personalised care approach for newly diagnosed people and support for bereaved relatives. Additionally, a new standard operating procedure was introduced to improve the accuracy of death recording after audit findings identified inconsistencies in documentation.

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 service worked with other providers to ensure continuity of care, including where clinical tasks were delegated to other services. We reviewed meeting minutes to confirm this.

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 people’s health, including those in the last 12 months of their lives, people 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, in collaboration with its patient participation group, recognised challenges within the wider healthcare system and worked together to identify ways to make people’s journey more seamless. This included improving service integration, ensuring timely screening and preventative measures, streamlining clinical pathways, and enhancing coordinated information sharing between services. The aim was for people to experience smoother care, fewer delays, better communication, and without needing to repeat their information, resulting in a more consistent and joined-up experience.

Whilst the service routinely monitored people’s care and treatment to continuously improve it, outcomes were not always positive, consistent, or in line with clinical expectations. This was reflected in the uptake of childhood immunisations and cervical screening.

Whilst the service team encouraged people to participate in population screening (e.g. the cervical screening programme) and the childhood immunisation programme, the service was not meeting national screening targets in these areas. The service was achieving 60-79% childhood immunisation coverage for 4 out of the 5 routine childhood vaccinations (against the World Health Organisation target of 95%) in 2024/25. Coverage was 37% for children aged 5 who had received 2 doses of the immunisation for measles, mumps, and rubella (MMR). Service data showed that children aged 0 – 5 years represented under 4% of the total service population.

The service identified low uptake in childhood immunisations as a priority area for improvement and undertook analysis to understand barriers affecting participation. Key challenges identified included vaccine hesitancy within specific communities; language and communication barriers; and limited awareness of immunisation schedules and their benefits. In response, the service had introduced targeted initiatives to improve childhood immunisation uptake, including personalised translated invitation letters in the 9 most commonly spoken languages of people registered with the service. The service also held ‘Immunisation Decliner Clinics’ led by its Screening Lead GP to address parental concerns. The service confirmed it had plans for a community engagement event to support education and service improvement. While the service continued to monitor performance, evaluate the effectiveness of interventions and provided evidence of improvement through unverified local performance data, the impact of the interventions was not yet reflected in nationally reported data.

In addition, the uptake rate for cervical screening was 43% for eligible people aged 50 to 64 years old, and 22% for people aged 25-49 (compared to the national target of 80%) in June 2024. Staff we spoke with informed us no ‘inadequate smear’ audits were undertaken (an ‘inadequate smear’ audit is a clinical review of rejected cervical screening samples to identify why a sample could not be processed). NHS Cervical Screening Programme guidance states that practitioners carrying out cervical screening are expected to review and reflect on rejected or inadequate test results. However, following our final visit, the service sent us evidence of inadequate smear audits dating back to 2024.

We also noted the service had recorded a significant rise in exception reporting over the past year to approximately 60%. (Exception reporting (Personalised Care Adjustments) in cervical screening excludes people from performance data for valid reasons such as non-attendance or clinical inappropriateness). The service advised that there was continued engagement with people and that people were given sufficient time and opportunity to attend before being excepted.

The service had identified low uptake in cervical screening as a key challenge and priority area for improvement. The service had already implemented a range of initiatives to improve cervical screening uptake. In an attempt to improve accessibility, screening provision was extended beyond North West London to 2 hub sites in East and South London in recognition of where people who used the service lived geographically. A subsequent outreach survey of people living outside the local area was carried out, and the service contacted approximately 4,000 people, with 309 responses received. Findings showed that 89% did not identify location as a barrier; the main reasons for non-attendance were not booking or seeing invitations, attending screening elsewhere, and work or caring commitments.

A customised template was then introduced to support non-clinical staff in carrying out accurate and sensitive conversations with people about cervical screening. This included details about anxiety support resources and direct booking links. Screening was also promoted through the service’s newsletter to its population. Further actions included a shared learning event with another GP provider, improvements to information materials, including a video tailored to the service’s population demographic and was available in multiple languages. The service had also secured endorsement to participate in a cervical screening self-testing pilot. While we observed evidence of community engagement and initiatives to increase uptake, their impact was not yet reflected in nationally reported data.

However, from the clinical notes we reviewed, we noted people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. There was a comprehensive programme of clinical audit and quality improvement activity to review the effectiveness and appropriateness of the care provided. For example, targeted training of clinical staff following an imaging request rejection audit resulted in a 62% improvement in approval rates.

In 2025, the service demonstrated a data-driven approach to monitoring and improving outcomes through its diabetes clinics initiative. The model used audit findings, group education, targeted outreach, and effective use of pharmacists to improve care delivery and outcomes for people using the service. The approach also supported inclusion through initiatives such as multilingual support and demonstrated effective use of resources.

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, including the Mental Capacity Act 2005. We reviewed a sample of records where DNACPR decisions had been documented. This showed that, where possible, people’s views had been considered and respected, and relevant information was shared with appropriate agencies.