Hazeldene Medical Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

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 66 (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 demonstrated a proactive and positive safety culture, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff and people felt supported to raise concerns, which were listened to, investigated, and used to drive improvement. Feedback from the service’s patient participation group showed concerns were taken seriously and acted upon.

There were clear systems for reporting and learning from incidents, near misses, and complaints, with shared learning discussed in team meetings. Staff described an open culture where safety was a priority.

The service also volunteered as an early adopter of the NHS Patient Safety Incident Response Framework (PSIRF) pilot for general practice, supporting a positive safety culture and learning from patient safety incidents to improve care.

Improvements were needed to ensure referrals were managed effectively and pathology results were reviewed in a timely manner to maintain patient safety. However, the service worked with people and healthcare partners to ensure there was continuity of care, including when people moved between different services.

As part of our assessment, we remotely undertook a series of clinical searches and records review to assess the service’s clinical care. During the remote clinical review, no concerns were identified in the management of pathology results. However, during our onsite visit in December 2025, we identified inconsistencies in the actioning of pathology results. A sample found 2 results from October with unclear review status and 3 abnormal results from December (3–6 days prior to the visit) awaiting review. The provider confirmed that whilst these were flagged as abnormal results, they were not urgent and took prompt action to review them and contact people where necessary. During the assessment, the service took immediate action and completed a pathology filing audit which identified only 89% of pathology results were being filed in line with its own standard operating procedure. Deviations from the standard operating procedure were identified and reviewed, and actions were taken to address these areas including refresher training for staff where appropriate. A re-audit was planned within six months.

There was a dedicated registration team and systems in place for processing information relating to people who were newly registered at the service. Newly registered people were offered a health check within 48 hours of registering.

Clinical pathways were established for a range of acute and chronic conditions, providing structured guidance to ensure consistent and effective management of people over time. The service worked with other providers to deliver shared care and when people moved between services. There was a designated team responsible for overseeing and monitoring referrals to support efficiency and continuity of care. However, during our first onsite visit in December 2025, we identified 176 referrals with associated tasks pending completion. By the time of our final onsite visit in February 2026, this had reduced to 50, demonstrating improved timeliness in progressing referrals through the pathway.

The service did not always ensure its coding of safeguarding arrangements for vulnerable people and their families were consistently updated and safeguarding training relevant to staff roles in line with national guidance was not fully embedded. However, the service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff. The service carried out searches to identify vulnerable people and acted on concerns in partnership with other organisations. However, the service’s coding of safeguarding was inconsistent. For example, clinical records of the adults in the same household were not always flagged to indicate there were children subject to safeguarding orders in the same household. Additionally, clinical records of people where there was a safeguarding concern were not always coded appropriately, reducing visibility of potential safeguarding risks.

The service’s standard operating procedure for mandatory training stated that non-clinical staff must complete Safeguarding Adults and Children Level 1 training; however, it did not differentiate training requirements for different non-clinical roles, including those with regular contact with people, such as receptionists, in line with national guidance. This meant there was a risk that staff may not have the appropriate level of safeguarding knowledge and competence to fulfil their responsibilities. On review of the service’s training records, it was noted non-clinical staff had not completed safeguarding training to the level required for their role. However, we did not identify any concerns when speaking with staff about safeguarding. Following our onsite visit in December 2025, the service ensured that non-clinical staff undertook safeguarding training immediately and at the level required for their role.

The provider was an early adopter of the Child Protection Information Sharing system (CP-IS2), an NHS-commissioned service that enables secure information sharing between local authorities and NHS organisations to help protect vulnerable children. This allowed staff to access real-time social care alerts, providing an additional layer of protection. This was particularly important as the service registered people nationally and operated across multiple local authority areas, where safeguarding information is often held separately.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

Staff could recognise a deteriorating person and knew what action to take. People were advised on risks related to their condition and actions to take if their condition deteriorated.

Emergency equipment and medicines were available and maintained at the clinical sites in Brent, North West London. Emergency medicines and equipment at the East and South London hub sites were managed by a third-party organisation from whom the service rented clinical rooms, and we saw evidence that these were appropriately maintained and regularly checked. These 2 sites were exclusively used to deliver cervical screening. A limited stock of emergency medicines was noted to be available at those sites, so the provider had undertaken a risk assessment to justify the absence of specific medicines, in line with the services offered.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

A business continuity plan was in place and subject to monitoring and review. The service undertook weekly health and safety checks to identify and address any risks to staff and people. Fire risk assessments had been recently updated for the 4 clinical sites and the staff-only headquarters site in North West London. The service was awaiting the documentation and action plans from these assessments undertaken by an external contractor. We noted that portable appliance testing (PAT) had not been undertaken at the headquarters site since the service began using the building in 2024. During our assessment, the service sent us evidence to confirm PAT testing had now been booked for January 2026.During the factual accuracy process, the service provided further evidence confirming that the PAT testing had been completed in January 2026.

The East and South London hub sites were managed by a third-party organisation from which the service rented clinical rooms. In April 2025, the service sought assurance that the third-party had completed appropriate health and safety assessments.

We observed damage to the reception area flooring at the Chamberlayne Road site, following an incident involving a car in June 2025. This presented a potential risk to the safety of staff and visitors and required remedial action. The provider responded promptly to our feedback and arranged for repairs. We also observed visible structural damage to the exterior of the building and large cracks in a store room wall that had been temporarily secured. The service was able to demonstrate it had escalated these concerns to the premises landlord prior to our assessment. The landlord subsequently arranged an inspection and advised there was no immediate risk to safety. The issue was recorded on the service’s risk register, and repairs were planned following the removal of nearby tree roots which had been identified as the cause of the damage.

The service made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision, and development. They worked together well to provide safe care that met people’s individual needs.

Safe recruitment practices were followed. We noted learning needs and staff development were managed appropriately, and staff were working within their agreed areas of competence. Monthly clinical safety audits were undertaken using an audit tool, reviewing a sample of consultations for each clinician, including locums, to monitor the quality and safety of care, identify areas for improvement, and ensure consistent clinical standards across the service. Any issues identified were discussed with clinicians and escalated where further support was required.

Records reviewed as part of this assessment showed that staff training deemed as mandatory by the service was up to date for most staff groups, with the exception of safeguarding training for non-clinical staff. This was rectified following our first site visit. Extended roles and specialist expertise were embedded across key clinical areas to enhance people’s care, reduce reliance on secondary care referrals, and strengthen both clinical and digital safety. For example, GPs held special interests in palliative care, frailty in older people, dermatology, and substance misuse. There were also GP leads for medical education and digital clinical safety.

The service’s model of care included rapid access to clinical advice. The service employed a range of clinical staff to assist with this model of care, including 32 pharmacists at the time of our assessment. Pharmacists reviewed the initial triage of appointment requests, streamlining subsequent GP triage and enabling GPs to focus on clinical decision-making. Pharmacists reported feeling well supported by the lead pharmacists; however, some highlighted that clinical supervision with their GP lead could be improved through more regular and structured arrangements. Other clinical staff informed us they were satisfied with the supervision they received.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading, although they did share concerns with appropriate agencies promptly.

Systems and processes for managing infection prevention and control (IPC) were not effective in ensuring risks were consistently identified, mitigated, and managed across all sites. For example, the service was not following its own IPC expectations at the Crest Medical Centre site. Clinical waste bags were observed to being used for non-clinical waste, a treatment couch was noted to be damaged and was still being used during appointments with people using the service, and there was an overflow of clinical waste stored in unsecured bins outside the premises. Following our first onsite visit, the provider took action to address the concerns identified. This included securing the external clinical waste bins with wall locks and replacing the damaged treatment couch.

In addition, the service’s own IPC audit findings identified consistent areas of non-compliance with national guidance. For example, the presence of incorrect pull cords in toilets, the absence of coved flooring in clinical areas, and the use of sinks and taps which were not appropriate for clinical areas. These actions remained outstanding, with no clear plan, timescales, or evidence of interim risk mitigation.Following the assessment, the service implemented a formal IPC improvement process with assigned leads, timescales and governance oversight. Environmental IPC improvements were identified across some clinical areas, with interim mitigation measures implemented where immediate replacement was not possible. Monitoring was strengthened through action plans with clear responsibilities and evidence of completion.

The service had a nominated IPC lead, and staff had completed relevant training. Cleaning schedules were in place and were being followed. The provider carried out risk assessments and audits, and actions had been identified to address risks. For example, antimicrobial stewardship toolkit training for staff had been updated. To further strengthen clinical leadership, the service had also appointed a new Nurse Director to provide stronger professional leadership and oversight in IPC.

The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They involved people in planning, including when changes happened.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff across all sites received regular training, were competency assessed on medicines optimisation, and felt confident in managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines across all sites were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Waste medicines were recorded and disposed of appropriately including medicines returned by people. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments across all sites.

The service had effective systems to manage and respond to safety alerts and medicine recalls. For example, our remote clinical search of the monitoring for people prescribed topiramate (a medicine prescribed to treat epilepsy and prevent migraine headaches) identified no issues. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. For example, people prescribed methotrexate (a medicine prescribed to treat autoimmune diseases) had received blood test monitoring within the recommended timescales before prescriptions were issued.

During our remote clinical searches, we identified 8 people for whom care could be enhanced or where further evidence was required, and we brought these cases to the provider’s attention. The provider responded promptly and conducted a thorough review of each case. We were assured by the rationale and supporting evidence provided, as well as by the actions taken to maintain and ensure people’s safety.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was lower than local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.