Hazeldene Medical Centre

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

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 had a shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.This was reflected in an embedded culture that prioritised improving outcomes for a diverse population. Leaders consistently translated these values into measurable actions, addressing health inequalities and enhancing people’s experiences and outcomes.

Staff were aware of the service vision and strategy, which was kept under review. The service demonstrated a good understanding of the challenges affecting its population and the wider local community. It recognised key local health and social care needs and was actively working with partner agencies to plan for and respond to current and future demand.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment, and support. Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty.

The service was previously registered with the CQC as a sole provider. In July 2025, the registration was updated to reflect a change to a partnership model, including the previous registered individual. The partners demonstrated an understanding of the demands on the service and had responded by expanding the senior leadership team to support a rapidly growing service.

Staff told us leaders in the service were approachable and responded to any concerns raised. We saw the leadership team worked with other services in the primary care network and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff interviewed told us that leaders and colleagues acted with openness and transparency. The provider conducted 3 staff surveys throughout the year to gather feedback and identify concerns, alongside informal opportunities for staff to raise issues.

The service had established Freedom to Speak up arrangements internally and externally with the local integrated care board. Staff were aware of how to raise concerns.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued. The provider promoted an inclusive workforce culture through regular communication and engagement. Weekly staff updates shared key information and recognition, alongside clinical newsletters produced by lead GPs for clinicians. The provider also conducted 3 staff surveys annually to gather feedback and support continuous improvement.

The service had a diverse workforce that reflected the local community it served. This supported an inclusive culture where staff brought a range of different backgrounds, experiences, perspectives, and skills to their roles. The diversity of the team helped the service better understand and respond to the needs of people using the service, ensuring that care and support were delivered in a culturally sensitive and person-centred way.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about performance and outcomes and share this securely with others when appropriate.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. Staff could access all required policies and procedures. Senior leaders held regular meetings to oversee regulation, operations, incidents, people’s feedback, performance, data security, safeguarding, and clinical leadership. Managers held regular service meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took confidentiality and information security seriously, with some team members undertaking extended roles in digital safety.
The provider had established governance processes appropriate to the service. However, inconsistencies in those processes being carried out were identified that had not been detected through existing systems, including in the monitoring of pathology results and referrals, maintaining infection prevention and control standards at 1 site, and ensuring appropriate safeguarding training for some non-clinical staff. The service demonstrated a strong learning culture by responding openly and promptly to identified risks. It strengthened governance systems and implemented sustainable improvements to reduce the likelihood of recurrence, including enhanced monitoring of pathology and referrals, improvements in infection prevention and control standards, and strengthened safeguarding training.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service developed impactful partnerships that improved outcomes for its population. These partnerships were used not only to collaborate, but to co-design and deliver solutions that addressed inequalities and improved access to care. The provider demonstrated measurable improvements for groups experiencing barriers, including increased uptake of carers’ health checks and strengthened, targeted support for veterans and other underserved populations. This collaborative approach enabled the service to better understand and respond to the needs of its population.

The service had a proactive patient participation group (PPG), which held both online and face-to-face meetings, rotating across the 4 North West London sites to maximise accessibility and engagement. The Chair of the PPG also served as a board member for the service, ensuring strong representation of people using the service within the organisation’s governance structures. This supported the inclusion of people’s views and experiences in decision-making and strengthened engagement with both internal teams and external stakeholders. A quarterly newsletter for people who used the service was published to share updates, promote services, and support people’s health and wellbeing. The June 2025 newsletter reached over 20,000 readers, while the October 2025 edition reached 12,500 readers.

The provider attended biweekly meetings with other practices within their Primary Care Network to collaborate on service improvement and delivery, including extended access. They also engaged with other GP providers to support shared learning and best practice.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. They actively contributed to safe, effective practice and research.

The service had a quality improvement plan in place to help drive improvements in services. This focussed on digital innovation, data-driven initiatives, access, and improving healthcare outcomes. All staff were encouraged to put forward and test out new ways of working.

The service demonstrated a commitment to staff development and upskilling. This was evidenced by funding administrative team members to undertake phlebotomy training, while clinical pharmacists were supported to pursue postgraduate qualifications and Advanced Clinical Practitioner training. This strengthened the service’s skill mix and ensured staff had the skills and knowledge to provide effective care and support. The service also supported learning by offering placements for medical, pharmacy, and business students. Feedback from both students and placement organisers was positive, with the service praised for its inclusive approach, supportive learning culture, and strong commitment to professional development.

The service demonstrated strong innovation and continuous quality improvement through a series of recognised achievements. A visit from the National Digital Team at NHS England in December 2025 highlighted the service’s contribution to digital transformation at scale and its role in shaping future national strategy through co-production of digital transformation initiatives with people who used the service. Also in 2025, the service won the National Quality in Care (QIC) Diabetes Award for a data-driven clinics initiative that improved outcomes through audit use, group education, and targeted outreach. The model showed cost-effectiveness, strong inclusion (including multilingual support), and effective use of pharmacists.

In 2024, through the GP Improvement Programme, the service had strengthened its Modern General Practice model by mapping people’s journeys, improving website accessibility, and introducing an ‘appropriate appointment’ questionnaire to support effective triage. These initiatives demonstrated measurable improvements in access, people’s experience, and outcomes. For example, appointment suitability improved, with the proportion of people reporting they were seen by the right professional increasing from 86.7% to 100%, demonstrating the effectiveness of the triage system in matching people with the most appropriate clinician. The service was also a finalist for the 2025 Digital Innovation Award, recognising its co-designed with its PPG of a 24/7 online consultation system, supported by a skilled triage team, to improve access and patient flow.

The service further demonstrated a proactive approach to innovation and population health by securing approval to participate in future pilots relevant to its population. This included involvement in a cervical screening self-testing pilot.

The PPG contributed to multiple aspects of service development, including providing feedback on initiatives, trialling innovative approaches, identifying patient challenges, proposing areas for research, and participating in health promotion and events. We saw examples of patient-led research aimed at addressing health inequalities and meeting the needs of the population. For example, the PPG had recognised the high prevalence of low-income households in the local area and led a patient pathway research initiative to improve access to GLP-1 therapies (prescription medicines primarily used to treat type 2 diabetes and obesity). This enabled engagement with people to explore barriers to access and identify ways to improve equitable provision.

People were also actively involved in testing pre-deployment digital systems, including the triage system, a Chatbot, and an AI voice agent. Feedback was collected through PPG sessions and questionnaires, with over 180 people engaged in recent structured digital access testing. This enabled the service to identify which systems were effective and user-friendly, as well as where improvements or adjustments were required.

Other areas of focus identified by people included cardiomyopathy, hypertension, cholesterol, chronic kidney disease, chronic obstructive pulmonary disease (COPD), vaccination uptake, and obesity. The PPG led a project delivering shared group consultations for people with diabetes to support education and self-management. People’s feedback was routinely collected and monitored across projects to inform service improvements and evidence impact.