Richmond Road 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

The service demonstrated an outstanding commitment to equity, proactively identifying and addressing barriers that could affect people’s access, experience or outcomes. Leaders and staff used population intelligence, patient feedback and community insight to shape services that met the diverse needs of their population. They took sustained, targeted action to reduce inequalities, remove delays and protect people’s rights, including making reasonable adjustments and tailoring support for those with protected characteristics. Resources were allocated thoughtfully to ensure all groups could benefit from timely, personalised and effective care, resulting in consistently positive experiences and improved outcomes across the community.

This service scored 93 (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 placed people at the centre of their care and treatment, working in partnership with them to respond to changes in need through proactive population surveillance, comprehensive care planning, named accountability and a structured access model that protected vulnerable patients from routine demand pressures.The service had completed annual health checks for all 19 patients on the learning disability register, with individualised care plans in place.

At the time of assessment, all of the 20 patients on the dementia registerhad care plans in place. All patients on the end-of-life register had been reviewed, with care plans updated on both EMIS and the UCP system, ensuring real-time access for urgent, out-of-hours and secondary care services. This supported consistent recognition of patients’ wishes across services.

The service maintained a register of over 220 carers, overseen by a named senior lead, with a dedicated Carers Champion providing a single point of contact. Newly identified carers received tailored information and access to a structured programme of workshops delivered in partnership with local services, supporting carers to manage their role and well-being. Flexible appointment arrangements further reduced the burden on carers.

A Priority Patient Scheme ensured daily same-day appointment capacity for vulnerable groups, including those with complex or urgent needs. Patients were identified proactively through clinical systems, ensuring timely access and reducing the risk of unmet need.

A review of DNACPR records confirmed decisions were appropriately applied and documented. National GP Patient Survey results showed that 90% of respondents felt involved in decisions about their care. Clinical records and patient feedback demonstrated that patients were supported to understand their conditions and were actively involved in care planning.

The service pioneered and implemented an Autism Friendly Practice model, becoming the first practice in Hackney to achieve formal accreditation. It introduced a range of tailored adjustments, including named GPs, longer appointments, environmental changes, flexible access and clear communication, supported by staff training and digital systems to ensure individual needs were consistently recognised. This work was co-designed with autistic people, improved access and experience, and was subsequently adopted across the primary care network and borough, gaining national recognition as an example of best practice.

During the factual accuracy process, the provider submitted additional evidence relating to their inclusive and person‑centred practice, which supported the uplift from 3 to 4.

Overall, the evidence showed a highly personalised, inclusive and innovative model of care, the Priority Patient Scheme ensuring timely access for vulnerable groups, and the nationally recognised Autism Friendly Practice model. Together, these consistently removed barriers to access and ensured people’s needs were understood and met, evidencing an outstanding level of person‑centred care.

The service demonstrated an exceptional understanding of the diverse health and care needs of its population and used this insight to design and deliver well-coordinated, flexible and continuous care across the practice, Primary Care Network, borough and wider system. Population data and patient feedback were used to shape a structured model of care, ensuring services were aligned to need and delivered in a joined-up way.

Care was coordinated across services through strong multidisciplinary working and shared systems. End-of-life care was supported through regular meetings involving GPs, district nurses, social care and palliative care teams, ensuring care plans were regularly reviewed, future needs anticipated and support provided at the right time. For housebound patients, a dedicated paramedic home visiting service provided regular reviews and continuity for those unable to attend the practice.

The service worked beyond traditional primary care boundaries to provide integrated support for patients with wider social needs. This included establishing and leading a monthly Health Hub, a drop-in community service where patients could access health, housing, financial, wellbeing and digital support in one place without needing a referral. This reduced barriers to access and helped patients receive more holistic support, while strengthening partnership working across primary care, the local authority and voluntary sector organisations.

The service carried out ongoing assessment of its population using data on demographics, demand and patient feedback to understand the needs of its diverse and growing community. It used this information to design how services were delivered, including offering multiple ways for patients to access care, such as online, by phone or in person, so people could choose the option that suited them best. Access was prioritised for vulnerable patients, and systems were in place to support continuity with preferred clinicians where possible, ensuring care was safe, fair and responsive.

The service also delivered annual Teddy Bear GP Clinics in partnership with local schools to support early health education and reduce anxiety around healthcare environments. Through interactive and engaging sessions, children were introduced to the GP setting in a safe and supportive way, helping to build confidence and improve understanding of health and well-being from an early age.

During the factual accuracy process, the provider submitted additional evidence relating to their community‑focused and person‑centred work, which supported an uplift in the score from 3 to 4.

This demonstrated an outstanding approach to care provision, as services were proactively designed around population need, extended beyond traditional clinical models, and delivered in accessible and innovative ways that improved engagement, experience and outcomes across the whole community.

The service demonstrated a notable approach to ensuring information was accessible, accurate and tailored to the needs of its diverse population. This was achieved through multilingual provision, proactive use of population health intelligence, dedicated administrative leadership, creative community engagement and innovative digital communication that extended clinical expertise beyond the consultation setting.

The service supported a population where English, Turkish and Bengali were commonly spoken. Language barriers were addressed through a combination of professional interpreting services and staff with in-house language skills, enabling patients to communicate directly in their preferred language. Information was available in multiple languages via the practice website, and reasonable adjustments were made for patients with disabilities, including access to British Sign Language interpretation. Information met the Accessible Information Standard, with alternative formats such as large print, easy read and audio available, ensuring patients could access and understand information in a way that met their needs.

The service enhanced accessibility further through the development of an Autism Friendly GP Practice model, ensuring that patients with autism could access information and care in an environment adapted to their communication and sensory needs.

The service used digital platforms to extend access to health information, maintaining an active social media presence and introducing a clinician-led video series delivering structured, evidence-based education. This supported patients to access reliable information outside of appointments and in formats aligned with their preferences.

The service adopted a targeted and intelligence-led approach to communicating with families about childhood immunisations. Population health tools were used to identify patients requiring contact, and communication was coordinated through a dedicated administrative role responsible for call and recall systems and follow-up. This was complemented by themed community events designed to provide information in a more accessible and engaging format for families who may not respond to traditional methods.

The service also delivered a sustained programme of free patient education, including workshops, antenatal classes and well-being sessions, covering topics informed by patient need and clinical priorities. These were delivered in a range of formats, including online and face-to-face sessions, supporting patients to better understand and manage their health.

A Digital Inclusion Programme ensured that patients who experienced barriers to accessing digital information were actively supported. This included large-scale engagement events, access to devices, peer support and one-to-one assistance, enabling patients to develop the skills and confidence to use online services and access health information independently.

During the factual accuracy process, the provider submitted additional evidence relating to the accessibility, quality and inclusivity of information provided to patients, which supported an uplift in the score from 3 to 4.

Taken together, the evidence demonstrated a service that delivered a highly proactive, inclusive and innovative approach to providing information, ensuring patients could access, understand and use information to support their health and well-being. National GP Patient Survey results showed that 91% of respondents felt the healthcare professional they saw had all the information they needed during their last appointment, compared to 90% locally and 92% nationally.

The latest national GP Patient Survey found that 85% of patients had stated the healthcare professional they last encountered was good at listening to them during their last appointment.

The service demonstrated a highly effective, multi-layered approach to listening to people, acting on feedback and communicating changes back to patients. This was achieved through structured complaints management, systematic use of survey data, active patient participation and transparent public feedback mechanisms.

Complaints were managed by a dedicated complaints manager within the senior management team, ensuring consistent and senior oversight. Complaints, alongside significant events, were reviewed regularly at governance and all-staff meetings, enabling shared learning and embedding a culture where feedback was used to drive improvement.

The service maintained a visible 'You Said, We Did' noticeboard, providing real-time evidence of changes implemented in response to patient feedback and closing the feedback loop transparently.

This approach was demonstrated in response to the 2025 GP Patient Survey, where the service developed a structured action plan addressing key themes. Concerns regarding access to a preferred GP were addressed through a redesigned appointment model, improving continuity from 25% to 81% within three months. Feedback on digital access led to a targeted improvement programme, including appointment of a Digital Champion and patient onboarding support, resulting in a 98% increase in NHS App usage, significantly higher than local and national trends. Early morning telephone congestion was addressed through telephony redesign, reducing peak demand by 40% and improving call response times.

In each case, the service demonstrated a clear feedback cycle, where concerns were identified, actions implemented, outcomes measured and results communicated back to patients through multiple channels.

The Patient Participation Group was active and influential, contributing to service redesign and community initiatives. This ensured patient involvement extended beyond feedback to co-design of services.

The service also demonstrated strong patient engagement through a high volume of unsolicited feedback, including over 2,000 five-star online reviews. Independent validation from Healthwatch confirmed consistently high levels of positive patient experience, significantly above local averages, and recognised the service as an example of effective patient engagement and work to reduce inequalities. The service was also invited to share its approach at system level, reflecting recognition beyond the organisation.

Patient experience measures supported this approach. National GP Patient Survey results indicated high levels of patient involvement in care, and Friends and Family Test results improved alongside service changes, demonstrating the impact of acting on feedback.

Overall, the service made it easy for people to share feedback and consistently demonstrated that patient views directly informed service delivery.

People could access care, treatment and support when they needed to and in a way that worked for them which was reinforced by an access to appointment protocol. This promoted equality, removed barriers or delays and protected their rights. Patients told us they could access clinical care when desired via different avenues.

In December 2025, the service introduced a redesigned access model, following a review of patient access, telephony demand, and feedback. The model simplified access routes, reduced reliance on early‑morning telephone contact, and strengthened continuity of care, while maintaining clinical safety during winter pressures.

Since implementation, the service achieved significant improvements despite a 9% increase in list size. Total telephone calls reduced by 29%, calls per 1,000 patients reduced by 35%, and 8 to 9 am call volumes fell by 40%. Call answering performance also improved, with calls answered within 10 minutes increasing by 21%.

A patient survey conducted in February 2026 showed high satisfaction, with 91% of patients finding the system easy to use and 92% satisfied with the timeliness of care. Continuity of care improved substantially, with over 80% of patients able to see their preferred GP when requested.

Overall, the redesigned access model reduced demand pressure, improved responsiveness, and strengthened relational continuity while maintaining safe and timely access.

Access performance was then continually monitored and refined through a structured governance framework. The service reviewed real‑time telephony, digital access, and appointment data, supported by workforce demand‑modelling to proactively align capacity with need. Clinical safety was maintained through daily duty GP oversight and regular audit of care navigation and triage decisions. Patient feedback from surveys, friends and family data, complaints, and patient participation group discussions directly informed further improvements, while access performance was also reviewed through an equity lens to ensure inclusive access across all patient groups. Benchmarking through primary care networks and system forums, alongside ongoing staff engagement and training, ensured the access model remained safe, responsive, and embedded across the service.

The latest national GP Patient Survey found that 81%of respondents described their experience of contacting the service by phone as easy, compared to 51% locally and 53% nationally. Eighty-four percent of patients described their overall experience of this service as good, which was above the local and national average.

In response to the 2025 national GP Patient Survey, the provider introduced a digital improvement programme aimed in part at increasing NHS app engagement as a route for patients to manage appointments and access services. Actions included launching a patient-facing campaign, appointing a digital champion to support onboarding, and providing service-based electronic devices to help patients set up the NHS app. As a result, NHS app registrations increased by 11% between January 2025 and January 2026. Monthly NHS app logins rose from 9,243 in January 2025 to 18,321 in January 2026, representing a 98% increase in usage.

Patients were able to book appointments directly via the NHS App. The service also used eConsult, which allowed patients to submit symptoms, request sick notes or ask administrative queries online, with clinical triage applied where appropriate. Patients unable to use the online system could contact the service by telephone or attend in person, where reception staff provided support. Reception staff had received care navigation training.

The provider strengthened access through partnership working at community, primary care network (PCN), borough and integrated care system levels. The service supported community engagement through well-being and prevention initiatives, delivered targeted programmes for children and families, and improved early access through school and youth outreach. Within the PCN, access data, continuity outcomes and digital uptake were shared to drive consistent improvement, alongside delivery of an appointment‑free multidisciplinary health hub. At borough level, the service led large‑scale access and vaccination programmes and vaccination catch‑up campaigns. Systems had been in place to recall and invite patients for childhood immunisations and cervical cancer screening.

Treatment rooms had been available on the ground floor, and an automatic door had been fitted to the entrance.

Staff and leaders demonstrated a highly proactive and intelligence-led approach to identifying and addressing inequalities in access, experience and outcomes. Population health data, community engagement and direct feedback were used to identify under-served groups and design targeted interventions with measurable impact.

The service developed a structured programme of equality-focused initiatives, each aligned to a clearly identified need and evaluated for impact. This included targeted support for patients experiencing digital exclusion. A sustained Digital Inclusion Programme combined community engagement events, device loan schemes, peer support and one-to-one assistance. This enabled patients to access online services and improved confidence in using digital healthcare, reducing barriers created by increasing reliance on digital access.

Targeted clinical quality improvement work also addressed disparities in health outcomes. A focused programme improved diabetes care process completion for housebound patients from 61% to 80%, and blood pressure control among Black patients under 80 with hypertension improved from 86% to 91%. These outcomes demonstrated measurable progress in reducing inequalities for groups at higher risk of poorer outcomes.

The service addressed inequalities affecting children and families through a range of targeted interventions. The service's Sports Academy was developed in response to high levels of childhood obesity in the local population, particularly among lower-income and ethnically diverse families and has supported over 200 children since its launch in 2024. The programme was co-designed with local families and delivered free weekly sessions, resulting in improved physical activity levels and 23% of participating children returning to a healthy weight range. Free antenatal classes, funded by the service, removed financial barriers to pregnancy support, improving confidence and preparedness for expectant parents.

The service also addressed inequalities in access and engagement for vulnerable and underserved groups. A drop-in Health Hub provided integrated support for patients facing housing, financial and well-being challenges, removing appointment barriers and enabling over 450 residents to access coordinated support. Targeted outreach to underserved communities, including a dedicated event for the local Latino American community, improved understanding of NHS access and reduced barriers linked to language and system awareness.

Equality in experience was supported through inclusive care practices. For example, preferred names and pronouns were consistently recorded and used for transgender patients, ensuring respectful and affirming interactions across all staff.

The impact of this sustained and targeted approach was demonstrated through large-scale engagement, with over 5,000 residents reached, more than 2,300 health checks delivered and over 900 referrals made to support services. Independent validation from Healthwatch confirmed consistently high levels of positive patient experience and recognised the service as an exemplar in addressing health inequalities. The service was also invited to share its approach at system-level forums, reflecting recognition beyond the organisation.

Additionally, the service delivered an annual “Santa Comes to Hackney” community initiative over four consecutive years, working in partnership with its Patient Participation Group and local volunteers to support families during the festive period. The initiative provided free gifts and inclusive festive experiences for children and families, including events at the practice, community outreach via a travelling Santa sleigh, and visits to local hospitals. This strengthened community engagement, reduced social isolation, and ensured that families facing financial or social challenges were able to participate in seasonal celebrations.

During the factual accuracy process, the provider submitted additional evidence relating to equity and patient experience, which supported an uplift in score from 3 to 4.

This demonstrated an outstanding approach to equity in experience, as the service combined practical support such as digital inclusion, accessible antenatal provision and community initiatives like “Santa Comes to Hackney” to reduce social, financial and access barriers, ensuring all patients could engage with care and feel included regardless of their circumstances. The provider had maintained processes to ensure people could register, including those in vulnerable circumstances such as homeless people and Travellers.

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.

People had been given the opportunity to express their wishes regarding DNACPR and were supported to plan their future care while they still had the capacity to do so. People’s decisions and what mattered to them had been reflected in personalised care plans, which had been shared with others when necessary. The patients we spoke to during the on-site assessment told us they had felt involved in decisions about their care and treatment.