Pennine Drive Practice

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

At our last assessment, we rated this key question as good. At this assessment, the rating has change and is now rated as requires improvement.

We looked for evidence that the surgery met people’s needs and whether patients could access services. We saw that 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. We reviewed feedback received from patients from the Friends and Family Test and feedback from the patient participation group (PPG) members we spoke to as part of this inspection. The practice was seeking to engage with its patient population and make services more accessible and effective. The practice told us that they offered reasonable adjustments and took people’s individual preferences into consideration during appointments and when providing information. For example, the practice provided information in formats to help patients understand their care, treatment and conditions, provided access to interpreters and provided longer appointments to patients with complex needs.

This service scored 61 (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 were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

As part of this inspection, we considered feedback from patients sent to us about the practice over the previous 12 months. We also asked the practice to display a poster for patients in the lead up to this inspection to ask them to contribute their views. Feedback received related to access to appointments and issues with contacting the practice by telephone.

Patient feedback we received from the National GP patient survey indicated 71% of patients who responded felt that the health professional they saw or spoke to was good at treating them with care and concern during their last GP appointment. This was lower than the local average GP score of 83% and lower than the national average score of 85%. 48% of patients who responded found the reception and administrative team at the practice helpful. This was markedly lower than the local average GP score of 79% and the national average score of 83%. A total of 101 surveys were completed by patients which was a completion rate of 25%. The practice told us that it was not aware of the national GP patient survey and consequently had not analysed the most recent results. The practice told us that it would review this following our inspection.

We saw evidence of the Friends and Family Feedback (FFT) data for the practice for the months of March, April and May 2025. In March 2025, a total of 49 responses were received out of 162 patients surveyed (30% response rate). The majority of the feedback was very good or good. In April 2024, a total of 48 responses were received out of 189 patients surveyed (25% response rate). The majority of the feedback was very good or good. In May 2025, a total of 45 responses were received out of 189 patients surveyed (24% response rate). The majority of the feedback was very good or good, with 3 negative comments received which related to issues with a repeat prescription, timely communication with the practice and care received during appointment. The practice reviewed the feedback provided by patients through the Friends and Family Feedback (FFT) tool and had conducted an audit. We saw the practice had identified and taken action following this audit.

The practice told us that it considered the demographics of the practice population, offered reasonable adjustments where required and took people’s preferences into consideration during appointments and when providing information. For example, the practice provided information in formats to help patients understand their care, treatment and conditions as well as having access to interpreters, the provision of longer appointments where required and conducting home visits where needed.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

The practice signposted patients to community services where required, including social prescribers, smoking cessation clinics and healthy eating programmes. A GP at the practice was the cancer and palliative care lead and liaised with the PCN in relation to virtual cancer wellbeing clinics, a PCN project. The practice attended monthly meetings held with North London hospices. The practice referred patients and liaised where appropriate with mental health services, sexual health services, the tissue viability nurse, respiratory nurse and diabetes nurse. Patients had a choice of booking appointments using the online consultation form, by telephone and in person.

Patients in vulnerable circumstances were able to register with the surgery, including those with no fixed abode such as homeless people and travellers. The practice adjusted the provision of services to meet the needs of people by booking longer appointments where required. The practice also ensured appointments for carers were flexible to their routines.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs, for example, leaflets in different languages and in large sized font.

The practice ensured the patient population had access to information that was beneficial to their health. The practice provided access to interpreters and had a hearing loop system that was due to be re-installed in the reception area. Patient feedback we reviewed from the National GP patient survey indicated 88% of patients who responded felt they had all the information they needed during about them during their last GP appointment. This was just below the local average GP score of 90% and the national average score of 92%. The practice listened to patients and signposted them to the right services where necessary. The practice website was available to as wide an audience as possible and had accessible tools such as translation, altering text size and a dyslexia friendly format.

The service did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They did not always involve people in decisions about their care or tell them what had changed as a result.

The practice had identified ways for people to share feedback and raise complaints about their care, treatment and support. The practice had a patient participation group and reviewed data from Friends and Family Test (FFT) feedback received. We reviewed FFT feedback for March, April and May 2025 and saw that comments were predominantly positive.

Patient feedback we received from the National GP patient survey indicated 76% of patients who responded said the healthcare professional they saw or spoke to was good at listening to them during their last GP appointment. This was below the local average GP score of 84% and the national average score of 87%. 81% of patients who responded were involved as much as they wanted to be in decisions about their care and treatment during their last GP appointment. This was below the local average GP score of 90% and the national average score of 91%.

Feedback we received from the National GP patient survey indicated 88% of patients who responded felt they had all the information they needed during about them during their last GP appointment. This was just below the local average GP score of 90% and the national average score of 92%. When we inspected, the practice had not analysed the results of the survey and assured us that it would review the feedback and put in place any actions required to address issues raised.

The practice had a patient participation group (PPG) and we saw evidence of meeting minutes from a meeting held in November 2024. The minutes noted that since the Covid-19 pandemic, PPG meetings had been delayed, and the practice would like more regular meetings and input from the PPG. The practice gave updates at this meeting related to services provided with PCN collaboration, long-term conditions and appointment availability. The patient attendees gave positive feedback in relation the services provided by the practice and some more negative comments in relation to telephone access. We spoke with 2 members of the PPG who told us that they were due to meet following our site visit. They told us that when the group had met previously, the practice had sought the views of patients and had told them that these issues would be reviewed. They felt that the practice had been open and honest in approach. They told us that there were ongoing issues in relation to access to and availability of appointments, system for requesting repeat prescriptions and call wait times.

The practice had identified ways for people to share feedback and raise complaints about their care, treatment and support. The practice had a complaints policy which was available for staff to refer to. Information was available for patients about how to make a complaint at the surgery, and on the practice’s website. The practice told us that the practice manager would speak with patients who had made a complaint to try and resolve issues in the first instance. The practice told us that it conducted an annual review of complaints identified trends in complaints, for example, call waiting times, and had worked to reduce the number of complaints relating to this issue by allocating more staff to answer calls. The practice had listened to telephone calls with staff for training purposes and now had call waiting on the telephone lines and sought to continuously improve in this area. The practice told us that learning from complaints was used as an opportunity for improvement and that complaints were discussed at clinical meetings, with meeting minutes available to view for staff not in attendance. The practice also discussed any concerns or complaints raised on an individual basis with staff members where required. Non-clinical staff members we spoke with told us that practice meetings were not held consistently. We provided feedback to the practice that practice meetings would allow a forum for information relating to complaints, learning and improvements to be cascaded to staff members to ensure consistency in messaging and understanding. During our site visit we reviewed the complaints log which was kept in the manager's office.

The service did not always make sure that people could access the care, support and treatment they needed when they needed it.

Patient feedback we received from the National GP patient survey indicated 38% of patients who responded found it easy to get through to the practice by phone. This was lower than the local average GP score of 52% and the national average score of 50%. 28% of patients who responded found it easy to contact the practice using their website. This was lower than the local average GP score of 46% and the national average score of 48%. 29% of patients who responded found it easy to contact the practice using the NHS App. This was lower than the local average GP score of 42% and lower than the national average score of 45%. 48% of patients who responded found the reception and administrative team at the practice helpful. This was lower than the local average GP score of 79% and lower than the national average score of 83%. 38% of patients who responded described their experience of contacting their GP practice as good. This was lower than the local average GP score of 67% and national average score of 67%. 50% of patients who responded described their overall experience of the practice as good. This was lower than the local average GP score of 72% and lower than the national average score of 74%. We spoke with the practice about the survey results, and they told us that no analysis of the published survey had been undertaken and therefore no action plan had been devised to improves access to services at the surgery for patients. The practice told us that it would review the survey results following our inspection.

The practice did not conduct its own internal patient survey to gauge the views of its patients, but did collate and monitor responses from the Family and Friends Test (FFT) and completed an audit reviewing the response for March, April and May 2025. We noted that the feedback received through this mechanism was predominantly positive.

The practice opening hours are 8am to 6:30pm Monday to Friday. The practice website informed patients that they could contact NHS 111 for urgent matters out of hours or patients were able to complete an online consultation form, and the practice would contact them before the end of the next working day for non-urgent matters. The practice told us that it reduced digital barriers for patients in its population groups who were unable to use the online consultation form. Patients were able to telephone the practice or attend in person to make an appointment. Reception staff were able to guide patients through the process of completing the form and using online services. The practice told us that most prescriptions were issued electronically and that it aimed to complete repeat prescription requests within 24 to 48 hours. The practice had links with a local pharmacy which assisted with this.

We noted during our site visit that the push button disabled access was not working at the front entrance to the practice. The practice told us that this had not been working for approximately 4 months and attempts to repair this had been unsuccessful. We further noted that the doorbell was too high for people who used wheelchairs to reach. The practice told us that the doorbell was moved to a higher position as this was being mis-used by some of the local population. They told us that patients were aware that they needed to knock on the reception window for them to be let into the practice.

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

Overall, feedback that we reviewed indicated that people found staff caring and helpful. Staff members had received training in equality and diversity and provided people with the right information and support to meet their needs. The practice had not reviewed the results of the published national GP patient survey, and we provided feedback that this should be actioned and areas for improvement should be identified. The practice was working to address its issues with access and was working with the PPG to make improvements. The practice offered longer appointments for patients with complex needs, carers and older people.

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.

The practice worked collaboratively with other healthcare providers to support patients with end-of-life care. As part of our inspection, we reviewed a sample of patient records where there was a do not attempt cardiopulmonary resuscitation (DNACPR) decision in place. We saw the decisions had been recorded in line with national guidance and according to the Mental Capacity Act. Care plans were updated according to the changing needs of patients. The wishes of the patients were respected. Advanced care planning discussions were held about long term care with patients and their relatives where appropriate. The practice provided patients with a copy of the DNACPR form and added it to its clinical records system, which was accessible by other services, for example, the ambulance service and palliative care team.