Richmond Road Medical Centre

On this page

• 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

Patients were regularly assessed, and care and treatment were delivered in line with current legislation and evidence-based guidelines. Quality improvement was embedded across the service, with staff routinely evaluating the impact of their work and using data intelligently to strengthen clinical practice and drive measurable improvements in care.Staff worked collaboratively and with other organisations to deliver care and treatment.

This service scored 88 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The systems in place ensured patients’ assessments were kept up to date, and staff had a clear understanding of their current health and care requirements. Patients were referred appropriately to ensure further evaluation and support where necessary. The service had mechanisms to identify and prioritise care for its most vulnerable individuals. For example, all patients with a learning disability were offered an annual health check, and reasonable adjustments were considered to support attendance. A register was maintained for patients with caring responsibilities, and the service worked closely with an on-site social prescriber to help them access community-based support. The service ensured care and treatment was effective by regularly reviewing people’s health, well-being, and communication preferences. Feedback from patients was positive, with many feeling involved in their assessments and confident that staff understood their personal and cultural circumstances. Reception staff were familiar with the local community and used digital flags in the care record system to highlight specific requirements, such as the need for longer appointments or interpreter support. Health reviews included checks on physical and emotional well-being, and clinical staff used structured templates to guide holistic assessments. The provider had systems to identify previously undiagnosed conditions, and staff referred individuals with social challenges, such as isolation or housing issues, to a social prescriber.

In addition, the service facilitated social groups that met on-site for tea, cake, and informal conversation, open to isolated patients.

The service planned and delivered care in line with current legislation and evidence‑based guidance. Staff were supported through regular briefings and protected learning time, and learning was incorporated into day‑to‑day practice. Outcomes from training and clinical updates were recorded and linked to clinical systems, supporting a clear audit trail between education and care delivery. Input from internal and external clinicians contributed to improvements in prescribing and referral processes.

Clinical outcomes reflected this approach. The service achieved 94.9% overall QOF performance for 2024–25, with 99.25% in the clinical domain and high performance across long‑term condition indicators.

Quality improvement activity and prescribing data showed positive progress over the review period. Medicines‑related monitoring improved following targeted action, antibiotic prescribing remained below local and national averages, and polypharmacy indicators showed a downward trend, with patients prioritised for structured medication review where appropriate.

The service undertook targeted work to address health inequalities. Completion of diabetes care processes for housebound patients increased, supported by home visiting, and outreach activity contributed to improved engagement among patients with hypertension and those who had previously found it difficult to access routine care.

A virtual group consultation model for chronic pain was used to support patients with self‑management and access to multidisciplinary input.

Clinical records showed that care was delivered in line with current guidance. Patients with long‑term conditions were appropriately monitored, and DNACPR decisions were documented in accordance with legal requirements.

The service demonstrated highly effective and proactive coordination across teams and services to support continuity of care and prevent gaps. Staff ensured that patients only needed to tell their story once by sharing assessments and relevant information, including communication and accessibility needs, at the point of referral.

A named clinical administrative buddy system ensured clear accountability for all correspondence, results and follow-up actions. This prevented delays, ensured timely review of information and reduced the risk of missed tasks between clinical sessions.

High-risk pathways were closely managed. All two-week-wait referrals were audited to confirm they were sent within 24 hours, with safety-netting processes in place to confirm attendance and follow up non-attendance. This ensured patients did not fall between primary and secondary care services.

End of life care plans were recorded across shared systems, enabling real-time access for ambulance, out-of-hours and secondary care teams. This ensured patients’ wishes were known and respected across services. The service maintained a structured end‑of‑life register, with all 53 patients having a Universal Care Plan in place and documented entries for resuscitation status, preferred place of care and preferred place of death, supported by regular review dates to ensure plans remained current. Regular multidisciplinary team meetings brought together health, social care and community professionals to coordinate care for patients with complex needs, supporting anticipatory care and reducing the risk of deterioration.

The service demonstrated strong system-wide integration. A primary care network level single referral pathway enabled streamlined access to well-being and social prescribing services. The referral process was structured, risk-aware and outcome-focused, integrating multiple services into a single pathway and ensuring patients were directed to the most appropriate support while addressing both clinical and wider determinants of health.

The service had also co‑founded Health Spot City and Hackney, an integrated adolescent GP service co‑located within Young Hackney’s Forest Road Youth Hub. This brought primary care into a trusted community setting and created a direct clinical and administrative link between the practice, Young Hackney, the CAMHS Alliance and the Children’s Integrated Commissioning Service. A salaried GP delivered the weekly clinic, with care linked back to primary care records, ensuring seamless continuity between the community-based service and the registered patient record.

Wider partnership working, including a neighbourhood leadership group, brought together health, social care and voluntary sector organisations to coordinate care across the community and support joint service development.

Integrated working was further strengthened through embedded collaboration with mental health services and a co-located adolescent service linking primary care with community and specialist provision. This improved access for underserved groups and ensured continuity between services.

During the factual accuracy process, the provider submitted additional evidence relating to coordination and multidisciplinary working, which supported the uplift from 3 to 4.

Overall, the combination of fully integrated end of life care planning, innovative community-based provision through Health Spot, and a streamlined, outcome-focused referral pathway demonstrated a level of coordination that proactively reduced risk, improved continuity and addressed the wider determinants of health.

Taken together, this represented an outstanding approach to how teams worked together to deliver seamless, person-centred care.

The service supported people to manage their health and well-being through a sustained, self-funded programme of preventative initiatives delivered across practice, community and digital settings. These addressed physical health, mental well-being, social isolation and wider determinants of health in a coordinated way.

Population-level impact was demonstrated through lower emergency care use, with AE attendance and emergency admission rates significantly below borough averages. Emergency admission rates were 18.5 per 1,000 patients compared with the City and Hackney average of 27.6 per 1,000, representing approximately 33% lower utilisation. This reflected a proactive, anticipatory model that identified and managed risk before crisis.

A wide-ranging physical activity and well-being offer included a practice-funded Sports Academy, developed in response to local childhood obesity data and co-designed with families. The programme combined free activity sessions with health education and resulted in increased physical activity and improvements in weight among participating children. Community initiatives, including family events and cycling programmes, further supported engagement and enabled opportunistic health promotion.

Mental health prevention was supported through a long-standing programme of funded well-being sessions, including mindfulness and yoga, delivered both in person and online. These provided accessible, non-clinical support alongside traditional treatment pathways and demonstrated sustained improvements in patient-reported well-being.

Targeted interventions supported patients with complex needs. A virtual group consultation programme for chronic pain combined peer support, lifestyle approaches and clinical input, improving patient-reported outcomes and subsequently being adopted by other Primary Care Networks.

The service also delivered a comprehensive programme of patient education, reaching a large number of patients through workshops led by clinical specialists and external experts. These sessions supported patients to make informed lifestyle changes and improve self-management. Additional initiatives included funded antenatal education and basic life support training, extending prevention into practical life skills.

Focused work addressed health inequalities and high-risk groups.Targeted diabetes engagement, supported by risk stratification, enabled patients with poorly controlled diabetes to access reviews and specialist input. Patients were also supported to access national programmes for smoking cessation, weight management and diabetes prevention, alongside digital therapeutic interventions.

A strong community presence extended the reach of health promotion beyond the service. Regular engagement at local events enabled delivery of health checks, brief interventions and signposting at scale. The practice also established a monthly Health Hub, providing access to housing, financial and well-being support, recognising the impact of social determinants on health outcomes.

Further targeted support included a dedicated housing and mental health clinic, improving access to wider support services and reducing demand on GP appointments for non-clinical issues.

Staff proactively identified patients at risk of deterioration, including vulnerable groups and those with caring responsibilities. This was supported through a structured access model that prioritised timely care for patients with the greatest need.

During the factual accuracy process, the provider submitted additional evidence relating to their preventative and well-being work, which supported the uplift from a score of 3 to a score of 4.

The inclusion of initiatives such as the co‑designed Sports Academy and annual family park runs demonstrated an outstanding, proactive approach to prevention, empowering people and families to adopt healthier lifestyles through sustained, accessible and community‑focused interventions.

The service routinely monitored and improved people’s care and treatment using population health intelligence, structured governance processes and proactive quality improvement activity. This resulted in sustained and measurable improvement across multiple clinical indicators, with outcomes consistently exceeding local and national benchmarks in several key areas.

Performance was monitored systematically through clinical systems, population health tools and regular governance forums, where data was reviewed and acted upon. Leaders used real-time monitoring of long-term condition uptake to ensure continuous oversight and timely intervention.

Significant and sustained improvement was demonstrated in childhood immunisation uptake despite a population with complex needs, including high mobility, deprivation and language barriers. The service implemented a targeted approach supported by dedicated roles, proactive engagement and continuous monitoring. Over three years, performance improved from below national benchmarks to approaching national targets, with nationally validated data showing achievement ranging from 77% to 89% for age 5 MMR. The provider told us that their own internal monitoring indicated a 36% increase in full immunisation coverage by age five, demonstrating substantial improvement in uptake, which, while unverified and not directly comparable with nationally validated datasets, suggested further improvement. This work was also recognised externally, with the service commissioned to lead a wider MMR catch up campaign.

For cervical screening, the national target of 80% uptake (NHS Digital, 30 June 2024) had not been met, with uptake at 67% for those aged 25–49 and 74% for those aged 50–64. The provider shared its own 2025 data which, although not validated through national reporting processes and therefore not directly comparable, indicated that the service had met the cervical screening target for the 50–64 age group.

Although national targets were not fully met, uptake had improved over time and a comprehensive, targeted approach was implemented to address known barriers within this population. The service recognised lower uptake in younger cohorts and implemented a targeted improvement strategy, including extended access, trauma-informed care, patient choice of clinician, personalised recall systems and opportunistic engagement during routine consultations. These actions reflected a proactive approach to addressing known barriers within the population.

Quality improvement activity was systematic and produced measurable outcomes. A coding audit identified patients with unrecognised chronic kidney disease, leading to appropriate coding, clinical review and optimisation of care for all affected patients. A chronic kidney disease (CKD) coding audit identified 38 patients meeting biochemical criteria for CKD who were not formally coded, leading to individual clinical review, appropriate coding, monitoring plans and cardiovascular risk optimisation for 100% of patients within the audit period. In addition, a bisphosphonate re-audit demonstrated monitoring and medication review compliance rising to over 90%.

Targeted inequality-focused work improved diabetes care completion for housebound patients and blood pressure control among Black patients, achieving and exceeding planned targets. A targeted diabetes initiative also engaged patients who had previously not attended routine care, supporting re-entry into the treatment pathway.

A structured mortality review process was embedded within the governance framework. Reviews confirmed that care planning was effective, with all patients who had documented preferences for their place of care dying in their preferred location.

Overall performance remained strong, with QOF achievement above national averages and maximum thresholds reached across local long‑term condition indicators. Lower emergency department attendance and hospital admission rates compared with the borough average demonstrated that proactive monitoring and management of long‑term conditions translated into measurable improvements in population health outcomes.

During the factual accuracy process, the provider submitted additional evidence relating to their continuous quality improvement work, which supported the uplift from 3 to 4.

This included further assurance around the identification of previously unrecognised CKD through audit and high levels of medication safety achieved through bisphosphonate monitoring. Taken together with the reductions in Accident and Emergency attendance and admissions, this demonstrated a consistent, data‑driven approach to early risk identification and measurable improvement, evidencing an outstanding standard of continuous quality improvement.

Clinicians understood the requirements of legislation and guidance when considering consent and decision-making. Consent was documented, and clinicians supported patients in making informed decisions. Where appropriate, mental capacity assessments were carried out and recorded.

A review of three DNACPR decisions confirmed they were made appropriately and in line with legislation. Relevant staff had completed training on the Mental Capacity Act.