Updated 24 April 2025
Date of assessment: 10-11 June 2025. Remote clinical searches were carried out on 11 June 2025. A site visit took place on 11 June 2025.
Pennine Drive Practice is situated at 6-8 Pennine Drive, Cricklewood, London, NW2 1PA and provides NHS primary medical services in the London Borough of Barnet to approximately 7,931 patients. The practice is registered with CQC to provide the regulated activities of: diagnostic and screening procedures; family planning; maternity and midwifery services; surgical procedures; and treatment of disease, disorder or injury. The practice clinical staff include 5 GP partners, 2 practice nurses, 2 healthcare assistants, a practice manager and a team of administration and reception staff. The practice is supported by 2 Primary Care Network (PCN) pharmacists. Information published by the UK Health Security Agency shows that deprivation within the practice population group is in the 5th decile when looking a practice deprivation. The lower the decile, the more deprived the practice population is relative to others. According to the latest available data, the ethnic make-up of the practice area is 50.87% White, 18.8% Asian, 15.64% Other ethnic groups, 8.98% Black and 5.71% Mixed. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
We inspected and rated this service under our previous methodology on 27 July 2016 (published 7 September 2016). The overall rating for the practice was good with the key questions for effective, caring, responsive and well-led rated as good and the key question of safe rated as requires improvement. A requirement notice was issued in relation to Regulation 12 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Safe care and treatment.
A follow up inspection was carried out on 10 May 2017 which reviewed the safe key question. Following this inspection, safe was rated as good.
This assessment was carried out due to an aged rating since the last inspection. The clinical remote searches were completed by a GP Specialist Advisor on 11 June 2025 and a site visit was completed on 12 June 2025. We assessed all of the quality statements for safe, effective, caring, responsive and well-led.
As a result of this inspection, we rated the practice as requires improvement in safe, responsive and well led and good in effective and caring. This gave the practice a new overall rating of requires improvement.
SAFE: The service had a learning culture and people could raise concerns. Managers investigated incidents and people were protected and kept safe. We found that the service could make improvements to understand and manage risks, particularly in relation to monitoring patients on high-risk medicines, monitoring patients with long-term conditions, ensuring staff training was up to date and to the correct level, ensuring pre-employment checks were completed and recorded for all staff members and ensuring effective cold chain management and monitoring of emergency equipment, and ensuring Patient Group Directions (PGDs) were signed consistently.
EFFECTIVE: People were involved in assessments of their needs. We found that some improvements could be made in relation to the delivery of patient care in line with current legislation, standards and evidence-based guidance. Patient needs were not always assessed in a timely manner. Staff worked with agencies involved in people’s care for the best outcomes and smooth transitions when moving between services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people and took decisions in people’s best interest where they did not have capacity.
CARING: People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.
RESPONSIVE: People were involved in decisions about their care. The service provided information people could understand. The service worked to eliminate discrimination. People received fair and equal care and treatment. People were involved in planning their care and understood options around choosing to withdraw or not receive care. Patient feedback received in the National GP patient survey sometimes fell below the local GP average and national average scores regarding patient satisfaction with services.
WELL-LED: Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. We found that whilst the practice had assurance and governance policies in place, improvements were needed in systems and processes.
We found breaches of regulations in relation to Regulation 12 Safe care and treatment and Regulation 17 Good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.