Pennine Drive Practice

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• 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

We assessed all quality statements for this key question and rated the practice as good for providing effective services.

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

We found that there were some improvements that 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. In particular, we saw that there was not always effective management of patients with some long-term conditions. We saw that care was delivered and reviewed in a coordinated way when different teams, services or organisations were involved. Staff were passionate about supporting patients to live healthier lives.

This service scored 62 (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 did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

Patient feedback gathered in the 2024 National GP patient survey (GPPS) indicated that 81% of patients felt their needs were met during their last general practice appointment. This was slightly lower than the local average GP practice score of 88% and lower than the national average GP practice score of 90%. A total of 101 surveys were completed by patients which was completion rate of 25%.

We noted the results of the National GP patient survey, where 52% of patients who responded said they had enough support from local services or organisations in the last 12 months to help manage their long-term conditions or illnesses. This was below the local GP average of 63% and the national average of 68%. The practice told us that it proactively worked to identify patients at risk of developing chronic conditions. The practice detected patients in the pre-diabetes range in NHS health checks and would discuss the impact of their monitoring levels and work with patients to attempt to stop the progression of diabetes. The practice adopted a holistic approach to lifestyle management and encouraged healthy eating programmes, gym attendance and use of social prescribers. The practice told us that it used searches on its clinical records system to identify patients with long-term conditions for recall for monitoring and sent text messages to patients to make appointments and followed up with telephone calls. Patients with suspected diabetes would see the healthcare assistant for a diagnostic test and information shared within clinicians for review and a care plan devised for future management.

During our assessment, a CQC GP specialist advisor reviewed patient records to check the management of patients with long-term conditions at the practice. These searches undertaken were visible to the practice. One search we looked at related to pre-diabetes checks. We conducted a search for patients with the possible diagnosis of diabetes following a blood test result and identified 8 patients out of 7932 patients where there was a potential missed diagnosis of diabetes. We reviewed 5 of these patients and found that 2 of the patients should have been coded as diabetic and required follow up for diabetes care. Following our inspection, the practice informed us it had reviewed both patients and had coded correctly and had allocated the administrative team tasks to book appointments with these patients for future management. No harm to patients had been identified.

We found that the practice was effectively managing patients with type 2 diabetes where there was risk of diabetes complications due to high blood glucose levels.

We reviewed patients with acute exacerbation of asthma who were prescribed 2 or more courses of rescue steroids in the last 12 months and found patients were appropriately monitored. We reviewed patients with Chronic Kidney Disease (CKD) stages 4 or 5 and identified 11 patients out of 35 patients with CKD stages 4 or 5 who potentially had not had the required monitoring. We reviewed 5 of these patients and identified one patient where this monitoring was overdue. The practice reviewed this patient’s record and told us that this patient was a ‘ghost’ patient and removed them from the list. All other patients we reviewed had been monitored appropriately.

We reviewed patients with hypothyroidism who had not had thyroid function test monitoring for 18 months and identified 7 out of 259 patients with hypothyroidism in our clinical searches. We reviewed 5 of these patients and observed that 1 patient had an abnormal result and had not received recent monitoring within the timeframes specified under clinical guidance. 3 of the patients we reviewed had already been contacted for monitoring by the practice and 2 patients had the quantity of their medicines reduced. One of the patients who had their repeat prescription reduced from two months to one month. We provided feedback that the practice should consider whether this was a sufficient reduction. Following our inspection, the practice told us that it had reviewed these patients and provided assurances.

We saw evidence in our clinical searches that medication reviews were being completed comprehensively.

The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

The practice told us it followed protocols and National Institute for Health and Care Excellence (NICE) guidelines to ensure safe care and treatment was delivered. The practice discussed guidance and changes in guidance at clinical meetings, which were held weekly. Staff members who could not attend meetings were able to view minutes on the shared drive. However, we found some systems needed improvement to ensure effective monitoring of patients’ care and treatment. Whilst the practice told us of its processes to ensure regular review of patients with long-term conditions, we concluded these processes needed strengthening based on the evidence we saw during our clinical searches in relation to potential missed diagnosis of diabetes and monitoring of patients with hypothyroidism.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

The practice told us clinical staff liaised with other health professionals to review patients with complex needs. Staff also told us that they worked with a variety of healthcare professionals and patients were referred to other services within the community. The practice gave an example of where a GP at the practice was the cancer and palliative care lead and liaised with the PCN and another practice in relation to virtual cancer wellbeing clinics, a PCN project. Monthly meetings were held with North London hospices, and the list of relevant patients was discussed and distributed amongst partners. The practice nurse told us that patients were advised about the community services available and provided with contacts where appropriate. The practice nurse liaised with other community teams, for example tissue viability, respiratory and diabetes nurses. The practice nurse attended the local practice nurse forum and shared ideas to improve care. The surgery was informed about accident and emergency attendances and followed up with patients as appropriate.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff members we spoke with told us patients could, with their consent, be referred to community services, including social prescribers, smoking cessation clinics and healthy eating programmes. The practice made referrals where appropriate to a mental health and wellbeing practitioner, dietician and to other PCN initiatives including a drop-in centre and food bank. The practice advocated a holistic approach, and staff told us that they were alert to, when speaking to patients, considering whether additional services may assist them. The practice made referrals to sexual health clinics and a GP at the practice ran intrauterine device clinics for patients who wished to use this service. The practice website had information to support fitness, smoking cessation and healthy food swaps.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The practice told us that there were systems in place to monitor patients with long-term conditions, and the clinical team regularly discussed patients at weekly clinical meetings. We saw some areas of good practice in the management of long-term conditions, for example, the management of patients with acute exacerbation of asthma, management of patients with CKD stages 4 or 5 and management of diabetes patients who had high blood glucose levels and increased risk of. We found the practice should make some improvements in relation to the management of patients with hypothyroidism and diagnosing diabetes.

The practice provided information on its involvement with virtual cancer wellbeing group clinics, where a GP at the practice was representing the practice as cancer lead. The project involved evening online virtual cancer well-being groups or evening one to one sessions by appointment. The groups consisted of 6 sessions, taking place every 2 to 3 weeks for approximately 90 minutes per session. Each practice involved was expected to deliver the group 3 times over the course of a year. The core purpose of the sessions was to support patients at every stage of their cancer journey, improve patient well-being, reduce feelings of isolation and provide a holistic approach to care.

We asked the practice to provide us with examples of clinical audits that had been undertaken in the last 12 months and 2 complete full-cycle audits including actions taken and outcomes achieved. The practice provided an implant audit which detailed the total implants inserted and removed from April 2023 and April 2024 and from April 2024 to April 2025. The audit briefly detailed further actions, for example, referring patients for further treatment. A further audit relating to the fitting of IUDs was provided which reviewed the type of device and number fitted between April 2023 and April 2024 and from April 2024 to April 2025. The audit briefly detailed that there were no complications and provided a short commentary on actions taken. The audits did not include any reflections about procedure, whether targets were being achieved or information about any improvements identified and action plans implemented following the analysis of information. The practice told us that PCN pharmacists who worked with the practice completed audits on medicines uses and gave an example of a recent audit which had been completed in relation to usage of medicines to treat sleeping problems or anxiety. We did not have sight of this audit at the time of inspection.

The practice had a rate of 61% for the uptake of cervical cancer screening, which was below the expected uptake rate of 80%. The practice told us how it was working towards improving and reducing the barriers to uptake. The practice supported working age women with earlier appointments. Clinical staff contacted patients who did not attend appointments and encouraged future attendance. The practice nurse contacted patients who needed assurance, provided clinical information and supported women who found the procedure traumatic. The practice had a protocol for staff to refer to which detailed the process for call and recall of this cohort of patients, information about improving attendance barriers to attendance. The practice had an appropriate process for the checking of results, following up results not received and a failsafe process.

The practice had not met the expected minimum 90% uptake for all of the childhood immunisation uptake indicators and had not met the World Health Organisation (WHO) based national target of 95% (the recommended standard for achieving herd immunity) for all of the childhood immunisation uptake indicators. The practice was close to achieving the 90% uptake target for the percentage of children aged 1 who had completed a primary course of immunisation for Diphtheria, Tetanus, Polio, Pertussis, Haemophilus influenza type b and Hepatitis B (87.2%). The uptake for the other childhood immunisation uptake indicators was between 70% and 80%. The practice told us how it was working towards improving and reducing the barriers to uptake. The practice had a policy which detailed its approach, which included actions such as: completing (where appropriate) postnatal checks and baby immunisation during the same day; following up all patients who do not attend with a telephone call; the nurse and GP addressing concerns about vaccine safety; and involving trust community members in outreach efforts (including faith leaders and other respected figure to promote vaccination).

The practice told people about their rights around consent, and these rights were respected when person-centred care and treatment were given to patients. Clinicians understood the requirements of legislation and guidance when considering consent and decision making. We saw that consent was documented appropriately. Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision. The practice completed Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions in line with relevant legislation.