The Care Quality Commission
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Pennine Drive Practice

Overall: Requires improvement read more about inspection ratings

6-8 Pennine Drive, Cricklewood, London, NW2 1PA (020) 8455 9977

Provided and run by:
Pennine Drive Practice

All Inspections

During an assessment under our new approach

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.

10 May 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pennine Drive Surgery on 27 July 2016. The overall rating for the practice was good with safe rated as requires improvement. The full comprehensive report on the inspection can be found by selecting the ‘all reports’ link for Pennine Drive Surgery our website at www.cqc.org.uk.

This focused inspection was carried out on 10 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulations that we identified in our previous inspection on 27 July 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated as good.

Our key findings were as follows:

  • PGD’s (Patient Group Directions) had been reviewed, signed and authorised in accordance with local and national guidelines for all nurses administering medicines at the practice.

  • Training records including copies of all mandatory training conducted by staff outside of the practice had been maintained in staff records

  • The practice had made further progress in developing quality outcome audits to ensure they were reflecting improvements over time.

  • The practice had developed arrangements for monitoring the use of prescription pads in accordance with national NHS guidelines.

  • Arrangements for staff appraisal had been reviewed to ensure that staff received an annual appraisal of their performance. The new system ensured that staff had their learning and development needs identified, planned and supported.

  • The practice had progressed plans to audit patient consent to ensure consent recording practices were robust throughout the practice.

At our previous inspection on 27 July 2016, we rated the practice as requires improvement for providing safe services as the practice had failed to ensure that PGD’s (Patient Group Directions) were reviewed, signed and authorised in accordance with local and national guidelines for all nurses administering medicines at the practice (a Patient Group Direction (PGD) is a written instruction for the sale, supply and/or administration of medicines to groups of patients who may not be individually identified before presentation for treatment). At this inspection we found arrangements for PGD’s were robust and reflective of local and national guidelines. Consequently, the practice is rated as good for providing safe services.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

27 July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pennine Drive Surgery on 27 July 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed. However, PGD’s (Patient Group Directions) had not been reviewed, signed and authorised in accordance with local and national guidelines for all nurses administering medicines at the practice. The process for overseeing the management of PGD’s required review to ensure that all nurses were authorised to administer medicines in line with legislation.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Implement an effective system around authorisation of PGD’s to ensure they are in place for all practice nursing staff including practice nurse locums. Ensure PGD’s (Patient Group Directions) are reviewed, signed and authorised in accordance with local and national guidelines for all nurses administering medicines at the practice.

The areas where the provider should make improvement are:

  • Ensure training records include copies of all mandatory training conducted by staff outside of the practice..

  • Review arrangements in relation to quality outcomes audits to ensure they are reflecting improvements over time.

  • Review arrangements for monitoring the use of prescription pads in accordance with national NHS guidelines.

  • Ensure that all staff receive an annual appraisal of their performance to ensure they are appropriately skilled and trained and that their learning and development needs are identified, planned and supported.

  • Consider conducting a patient consent audit to ensure consent recording practices are robust throughout the practice.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

26 June 2014

During an inspection looking at part of the service

When we inspected on 06 May 2014, the provider was unable to evidence that infection control risk assessments had taken place to determine frequency and intensity of cleaning. Subsequently, there was no cleaning schedule in place to guide cleaning staff on frequency and intensity or to record when and how specific areas had been cleaned. Also, cleaning equipment was not colour coded according to the area of usage. This meant that the provider was failing to comply with the requirements of Regulation 12(1) (2)(a)(c)(i) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We asked the provider to take action.

When we inspected the practice again on 26 June 2014, we found that the provider had undertaken an infection control risk assessment and introduced a cleaning schedule determining cleaning frequency, intensity and allowing a cleaning record to be made of specific areas. Colour coded cleaning equipment had also been purchased. The action taken by the provider was sufficient to comply with the requirements of the regulation.

6 May 2014

During an inspection in response to concerns

Patients who used the service were given appropriate information and support regarding their care and treatment. Latest patient survey results showed that most patients rated explanations from their doctor as either 'excellent' or 'very good.'

Patient's care and treatment reflected relevant research and guidance. We saw evidence that the practice manager regularly received NHS guidance updates and that these were forwarded to staff.

Provider records showed that an infection control audit had taken place in February 2014 and that subsequent infection control/prevention measures had been implemented. However, the provider was unable to evidence that risk assessments had been undertaken to determine cleaning frequency and intensity.

Patients were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. The provider's emergency drugs were accessible and their expiration dates regularly checked.

Patients were asked for their views about their care and treatment and they were acted on. We spoke with a member of the practice's Patient Group. They spoke positively about patient involvement and how the views of the group had been taken on board.