Hazeldene Medical Centre

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 service met people’s needs, and that staff treated people equally and without discrimination.

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 79 (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 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.

Care plans reflected physical, mental, emotional, and social needs of people including those related to protected characteristics under the Equality Act. Our review of clinical records showed people were supported to understand their condition and were involved in planning for their care needs. They were also involved in decisions about their care.

The service demonstrated a patient-centred approach beyond individual consultations. It used the views and lived experience of people and communities to inform how care and services were delivered, tailoring pathways and improving accessibility to reflect the needs of its diverse population. This included consideration of the needs of carers, veterans and groups experiencing inequalities.

The service 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 service told us they worked in partnership with other services to meet the needs of its population. The service had tailored its services to meet the diverse needs of its community, for example, building relationships with community services, secondary care providers, and people. These relationships improved the service’s understanding of frailty, increased awareness of support services, and promoted personalised care, particularly for older people and those with long-term conditions, while strengthening community engagement.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Information to promote the take-up of screening and immunisation programmes was available in a range of languages. For example, an information video on cervical screening was available in multiple languages, reflecting the needs and demographics of the local population. The service had access to interpreter services, including British Sign Language, as well as real-time translation for front of house staff. Information provided by the service met the Accessible Information Standard. People were informed as to how to access their care records.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment, and support. They involved people in decisions about their care and told them what had changed as a result.

Complaints were managed in line with the service’s policy. Learning from complaints was evident and staff were able to identify changes made as a result of people’s feedback, including complaints. For example, in response to people’s complaints about communication, the service appointed a patient liaison officer to help improve communication with people.

The patient participant group (PPG) chair spoke positively about their interactions with the service, highlighting the quality of care and the responsiveness of staff in implementing service improvements based on people’s feedback. PPG feedback described the service as transparent and patient-centred, with a culture of recognising areas for improvement, acting on concerns, and involving people in decision-making, including the development and trial of new initiatives.

The service monitored people’s experience on a monthly basis through online reviews, complaints, and feedback via instant messaging services. Results from the NHS Friends and Family Test for September and October 2025 showed that over 80% of respondents would recommend the service.

The service made sure that people could access the care, support, and treatment they needed when they needed it. A range of access options, including online, face-to-face and telephone appointments, were provided to meet people’s needs. Reasonable adjustments were made to promote equitable access, such as offering extended appointments for people requiring additional consultation time. Treatment rooms were available on the ground floor and all sites, with the exception of Chamberlayne Road Surgery, were wheelchair accessible. People seeking to register at the Chamberlayne Road site were directed to an alternative site better suited to meet their needs.

The service applied clear criteria when considering new registrations to ensure safe and appropriate care. For example, children under 14 years of age were only registered at the service if a parent or guardian was also registered. For children known to the local authority, guardians were encouraged to register them with a local GP as part of their care plan. People who were frail, receiving palliative care, or otherwise unable to attend the service were supported to register locally, as out-of-area home visits could not be provided. Similarly, people with complex medical or mental health needs requiring regular face-to-face care were advised to register with a more local practice, with support offered to facilitate this where needed. Data supplied by the service showed that 54% of people registered at the service lived in North West London, and 95% of people registered at the service lived within London. Data from the 2025 national GP Patient Survey, along with feedback received by the CQC was in relation to the previous provider’s registration of this service. The themes of feedback were variable, with some people reporting easy access to appointments and minimal waiting times, whilst others described difficulties accessing face to face appointments and seeing the clinician of their choice (i.e. wishing to see a GP rather than a pharmacist). The current provider demonstrated awareness of this feedback and had identified areas for improvement in people’s experience of accessing the service. For example, the service now used a digital triage and communication system to manage access. This supported the prioritisation of requests, directed people to the most appropriate service or clinician via a primary and secondary triage process, and helped improve response times and workflow efficiency. The service offered evening and weekend clinics in response to high demand, improving access to appointments. People were also able to submit enquiries 24 hours a day through online systems, with responses provided during core working hours.

The service supported people to access GP services online where appropriate, including helping them register for, and use, the NHS App and online consultation tools. SMS links were used to facilitate access, alongside clear non-digital alternatives for those identified as digitally excluded. Social prescribers identified and supported people with limited digital access, particularly those with financial constraints, multiple long-term conditions, or social vulnerability. They also provided digital literacy support, including assistance with using online services, accessing reliable health information, and maintaining connections with wider support networks.

Staff spoke a wide range of languages aligned with the needs of the local population, with interpreting services and real-time translation tools available to reception staff to support communication. The service also introduced alternative communication channels (via an instant messaging application), co-designed with its patient participation group, and actively involved people in testing and refining digital access systems to ensure they were accessible, safe, and inclusive. People’s feedback collated by the service had been positive about this. All feedback was reviewed and used to improve safety, usability, and people’s experience prior to full implementation. A strong focus was maintained on accessibility, digital inclusion, and ease of use to ensure services met the needs of the diverse population.

Staff and leaders were innovative in how they listened to information about people who were most likely to experience inequality in experiences or outcomes. Staff and leaders actively used this information to provide exceptionally tailored care, support, and treatment in response to this.

The service recognised it served a highly diverse population, with service data showing people spoke 149 languages. The service identified that this presented challenges around access, language, and trust, but staff employed by the service reflected its community and spoke the 9 most commonly used languages, supporting effective communication with people.

Staff used appropriate systems to capture and review feedback from people using the service, including those who did not speak English or have access to the internet. The service participated in a translation pilot, using a digital tablet to provide instant translation in the most commonly used languages. Staff informed us that this had led to improving communication and accessibility for non-English speaking people.

Staff treated people equally and without discrimination. Leaders proactively sought ways to address any barriers to improving people’s experience and worked with local organisations, including within the voluntary sector, to address any local health inequalities. For example, the service improved identification and support for carers through a proactive outreach approach. A digital questionnaire enabled carers to engage at their convenience, increasing health check uptake from 13% to 34% in 5 weeks. The digital approach enabled flexible access, with holistic assessment and targeted follow-up for those with identified needs. Non-responders were actively recalled, and clinical record coding ensured carers were identified, and received appropriate and personalised support such as health checks and vaccinations.

Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes. The provider had processes to ensure people could register at the service, including those in vulnerable circumstances, such as homeless people and Travellers.

The service further promoted equity in experiences by addressing digital exclusion and language barriers within its diverse population. It worked in partnership with a digital inclusion charity to provide mobile devices and connectivity for people on low incomes and implemented inclusive digital systems that supported multiple languages.

The service identified military veterans at point of registration and, as an accredited veteran-friendly service, delivered targeted support to 339 veterans currently registered at the service. A digital questionnaire was used to provide information and referral links for mental health and wellbeing services, resulting in strong engagement: 68% of respondents expressed interest in mental health support, with 50% going on to complete an online self-referral as a result of the questionnaire. In addition, 61% of respondents requested a referral for physical health needs. Inclusive communication methods, including digital, email and postal outreach, were used to reach all people. The service had plans to increase awareness and evaluate ongoing engagement and equity for this demographic.

The service was recognised as a ‘Safe Surgery’ and had committed to tackling barriers migrants face in accessing healthcare, ensuring equitable and inclusive access to services for all people. The service was also a ‘Gambling Harms’ accredited practice, committed to improving outcomes for affected people through staff awareness and training, reduced stigma, appropriate signposting, and promotion of available support resources.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life. A GP with an Extended Role in Palliative and End of Life Care provided clinical leadership, oversight, and staff training, supporting coordinated and high-quality care for people approaching the end of their lives.

Our records review showed people were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. This information was shared with other services when necessary.

A resource pack was made available for individuals caring for or supporting people at the end of life. This included information on local services and support available within Brent to ensure people and carers were appropriately signposted.