Pennine Drive Practice

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed all 8 quality statements from this key question. At our last assessment, we rated this key question as good. At this assessment, the rating has changed and is now rated as requires improvement.

We found that the service was not always providing safe care because the provider did not always adhere to best practice guidelines in the monitoring and administration of high-risk medicines, in particular patients prescribed medicine used to control regular or rapid heart rate and patients who were elderly and on oral non-steroidal anti-inflammatory (NSAID) medicines (medicines used to relieve pain, reduce swelling and bring down high temperatures) where no proton pump inhibitor (PPI) (medicines that reduce stomach acid production) was prescribed. We found that the system for managing and acting on Medicines and Healthcare Products Regulatory Agency (MHRA) alerts was not effective. We saw that patients prescribed a medicine used to treat the symptoms of an overactive bladder had not always been monitored appropriately. We additionally had concerns in relation to the systems and processes in place for ensuring pre-employment checks were recorded for all staff members, completion of appraisals for all staff members, ensuring cold chain management and effective monitoring of emergency equipment, ensuring Patient Group Directions (PGDs) were signed consistently and effective oversight of staff training. The practice was in breach of regulation in relation to the provision of safe services.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice told us that it encouraged a culture of safety, based on openness and honesty without apportioning blame. The practice told us that it encouraged staff to report significant events when they arose and stated that it documented and discussed significant events and complaints as quickly as possible, identified actions and implemented learning where appropriate. The practice told us that it reviewed significant events and complaints on a quarterly basis. Staff members we spoke with were aware of practice policies regarding significant events and complaints and were able to access these. The practice told us that clinical staff attended weekly meetings and that significant events and complaints were discussed at these meetings. The practice informed us that meetings with non-clinical staff were held infrequently due to difficulties in gathering all staff together at the same time and that changes and improvements were communicated to staff members on an individual basis by the practice manager. We provided feedback to the practice that the lack of team meetings may not ensure consistency of messaging and missed learning opportunities for staff to discuss the learning with peers in these meetings.

We saw evidence that the practice listened to concerns, investigated and took appropriate actions. Staff members we spoke with were aware of the process of raising significant events and stated that staff and management would work together to learn lessons and improve processes. The practice had a significant events policy. The practice completed a significant event analysis tool following incidents which included a summary of the event, the outcome, an assessment of the likelihood of recurrence, consequences of recurrence and an action plan. The practice kept paper copies of complaints in a file. Patients were able to make complaints using an online form on the practice website and the practice had a complaints leaflet that was available at the surgery.

The practice had a referrals protocol and referrals policy which outlined the process for staff to ensure timely referrals and follow up. Staff members we spoke with understood their responsibilities to process routine and urgent cancer referrals and to follow up other urgent referrals. The practice had a designated member of administrative staff who conducted a search on the system to ensure that patients who had been referred under the urgent protocol had received appointments. The practice utilised an electronic document management and workflow system, and had a protocol which staff could refer to. The practice told us that clinicians had a named inbox and would check and clear the system each day. If a clinician was to be away, they would ensure that a named person was in place to review documents received. A named administrator would review the workload on an electronic documentation system to ensure that no backlogs accrued.

The practice worked with people and healthcare partners to ensure and maintain safe systems of care, in which safety was managed and monitored. The service worked with other care providers in the community to deliver shared care and when patients moved between services.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

Staff members we spoke with demonstrated an understanding of the practice’s safeguarding adult and children policies and told us about the method of escalation if a safeguarding incident arose. Staff members were able to access recently updated safeguarding policies on the shared drive. The practice held adult and children safeguarding registers which were reviewed on a regular basis, and the practice told us that it had recently held a safeguarding meeting with the GP partners and practice manager to go through both lists in detail. The practice discussed safeguarding information at clinical meetings. The practice provided us with examples of what safety mechanisms were in place if a patient did not attend a secondary care appointment or where there were Accident and Emergency attendances. The practice told us that it would follow up patients and continuously monitor and add a safeguarding code on the system if required. Staff members provided us with examples of how they would escalate and liaise with healthcare partners if necessary.

The practice manager had oversight of staff training. We noted that some members of staff had not completed the appropriate level of safeguarding training for their role. We saw in the training records provided by the practice that 11 reception and administrative staff had completed level 1 adults safeguarding training. 1 member of staff had not completed any safeguarding adults training. We saw that 10 reception and administrative staff had completed level 1 children safeguarding training. 2 members of staff had not completed this training.

We reviewed the training records for clinical staff members and noted that not all nursing staff had completed the appropriate levels of safeguarding adults and children training for their role. We saw that nursing staff had completed level 1 adults safeguarding training and level 2 children safeguarding training.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Results from the national GP Patient Survey for questions relating to patients being involved in decisions about their care and treatment show that the practice was slightly below the expected national target. 81% of patients who responded said they were as involved as much as they wanted to be in decisions about their care and treatment, which was below the local average GP score of 90% and the national average score of 91%. The practice told us that it was not aware of the national GP patient survey and consequently had not analysed the results of the survey.

During this inspection, we saw evidence that staff understood their role in involving people in making decisions about their care and treatment. Risks were identified and discussed with people and documented in patient records such as do not attempt cardiovascular resuscitation (DNACPR) decisions.

We saw evidence of patients being involved in the management of their long-term conditions and were given opportunities to choose different ways to manage their health. The practice told us that it had a holistic approach and a proactive approach to lifestyle management. 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 Primary Care Network (PCN) and another practice in relation to virtual cancer wellbeing clinics, a PCN project. The practice told us that it would take into account the diversity of its population groups to ensure that service delivery met the health and social care needs of the community. The practice had members of staff who spoke languages other than English including Punjabi and Hindu and the practice utilised translation services where it could not provide an interpreter for a patient.

The practice was equipped to respond to medical emergencies, including suspected sepsis and staff members we spoke with were aware of what action to take in the event of a medical emergency, how to escalate concerns and raise an alarm. However training records we reviewed did not demonstrate that all staff were up to date with basic life support and sepsis awareness training.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The provider ensured equipment, facilities and technology supported the delivery of safe care. We observed the premises was well maintained and there were systems in place to ensure equipment was safe. We found there were up to date fire, health and safety and Legionella risk assessments with action plans completed by the practice following these assessments. There was evidence the surgery had systems for safely managing healthcare waste. Staff had completed the appropriate fire and health and safety training. The practice had a personal and general emergency evacuation plan policy, fire safety policy and fire marshal warden guidance which was available for all staff. The practice told us that it had recently had a fire drill but that this was not planned and not logged. The last fire drill was some time ago. The practice should ensure that regular, documented fire drills take place. We noted a fridge kept in the reception area had not had portable appliance testing (PAT). This should be completed to ensure that the fridge is safe for use (this is not used to store vaccinations). The practice had a business continuity plan and staff members we spoke with were aware of how and where to access this.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

We reviewed staff files for two clinical and two non-clinical members of staff. We found that the staff records were not completed with all the required pre-employment checks documented within the files. The practice had a recruitment policy and procedure; however, we found that this was not always being adhered to. We saw that Disclosure and Barring Service checks were not always conducted in line with the practice policy. We did not see evidence of registration revalidation checks for clinical staff. The practice told us that members of nursing staff showed their professional registration to managers, but this was not documented within their staff files. We did not always find proof of identity in staff files. We found that some staff files did not contain references. We provided feedback to the practice that staff files needed to include DBS certificates completed by the practice and retained on file, identification checks, immunisation information and professional regulation checks where appropriate. The practice told us that it would take action following our inspection to ensure that staff files were kept up to date.

The practice had a recently implemented performance appraisal policy and procedure; however, we found that this was not being adhered to. We did not see any annual formal appraisals in staff files. The practice told us that staff appraisals were not always within staff files. The practice informed us that regular one to one meetings were held with staff members where training needs and objectives were discussed.

The practice manager was responsible for the overseeing of staff inductions and staff training. The practice had a document that detailed the role specific training requirements for all staff. We did not see evidence that staff had consistently completed or had undertaken training in basic life support, fire safety, Mental Capacity Act, safeguarding adults and children (to the appropriate level for their role) and sepsis awareness training.

The practice supported staff in their development, for example, it had trained staff members in extra roles and lead roles such as prescribing administration. The practice told us that clinics were supervised and that the GP partners conducted random checks of clinical notes. The practice encouraged clinical staff to seek a second opinion from another clinician where required and there was an open culture of learning. The practice informed us that a partner supervised the PCN pharmacists who worked with the practice and that prescribing audits were completed.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

During the onsite inspection we observed two closed sharps boxes in a consultation room and an open sharps box in the staff area on the upper floor. The practice told us that the sharps box in the staff room did not contain sharps and confirmed that it had been removed after we provided feedback. The practice confirmed that one of the sharps boxes in the consultation room was half closed and that the other would be checked. We provided feedback that closed sharps boxes should be dated and the staff member’s initials added before disposal.

During our site visit we found that fridge temperatures had not been monitored in line with national guidance. The practice told us that this was due to staff sickness. We provided feedback to the practice that fridge temperature checks must be conducted regularly, at least once daily at the same time, and this should be recorded. The practice did use a data logger during this period and reviewed the temperatures, and there was a system to monitor temperatures recorded outside of the expected temperature range. We provided feedback that even with data loggers used, the daily temperature checks should take place and be recorded to ensure that cold chain breaches were not missed. We noted that the practice’s cold chain policy detailed that daily temperature checks should take place in addition to the use of a data logger and the practice should consider implementing a protocol to ensure that staff were available to deputise in the absence of staff who normally conducted the temperature checks.

During the onsite inspection we found that the hand gel dispenser in the reception area was empty and the downstairs disabled toilet had damaged sealant by the skirting board, which would make thorough cleaning difficult. In addition, blinds in the downstairs reception area were not visibly clean and in a well-maintained condition.

The practice had an infection prevention control handbook which was available for staff, although this did not have a date of issue or date of review included. We saw that a GP partner was the designated lead for infection prevention and control (IPC) and was supported by the practice manager and practice nurse. We saw evidence that the practice had completed IPC audits.

We saw evidence staff vaccinations were up to date in line with UK Health Security Agency (UKHSA) guidance.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

We carried out remote clinical searches of patient records as part of our assessment to review if the practice was assessing and delivering care and treatment in line with current legislation, standards and evidence-based guidance. The practice had a prescription management policy, which was prepared by the Primary Care Network (PCN) pharmacy team. We noted that monitoring was not always consistent with this policy.

We found some concerns in relation to the monitoring and prescribing of some high-risk medicines. In particular, we reviewed patients prescribed Amiodarone (medicine used to control regular or rapid heart rate) in our clinical searches and found 11 patients prescribed this medicine. Of these 11 patients, 5 were identified as having outstanding monitoring. We noted that 4 of these patients had not had monitoring completed in line with guidelines. The practice told us that it would review patients prescribed this medicine. Following our inspection, the practice informed us that two of the patients had blood testing in a hospital setting and had now coded these results on the clinical system and confirmed that the administrative team had been allocated tasks to book appropriate monitoring for the other patients. The practice removed this medicine from the prescription for one of the 5 patients.

We reviewed the practice’s processes for implementation of patient safety alerts and found that this was not always being adhered to. We reviewed a Medicines and Healthcare Products Regulatory Agency (MHRA) alert relating to the prescribing of Mirabegron (a medicine used to treat the symptoms of an overactive bladder). We identified 7 patients in our clinical searches and reviewed 5 of these patients. Of these 5 patients, we found that 3 patients had not had blood pressure checks completed in line with guidelines and 2 of the patients had been followed up by the practice for blood pressure monitoring. The practice told us that it would review patients prescribed this medicine and ensure that the appropriate monitoring was undertaken. We saw evidence that the PCN pharmacists maintained a log for MHRA alerts. The practice told us that alerts were received centrally and were actioned by the PCN pharmacists; however, we could not be assured that the process for managing patient safety alerts was sufficiently robust due to our findings in relation to patients prescribed Mirebegron. The practice told us that it would review patients prescribed this medicine and following our inspection, the practice confirmed that the administrative team had been allocated tasks to book monitoring for patients where required. The practice informed us that it had added the blood pressure monitoring completed in a hospital setting to the clinical records of one patient.

We reviewed patients who were elderly and on oral non-steroidal anti-inflammatory (NSAID) medicines (medicines used to relieve pain, reduce swelling and bring down high temperatures) in our clinical searches and found 32 patients where no medicine which reduces the amount of acid in the stomach were prescribed. We reviewed 5 of these patients and found 4 patients who had not been prescribed this medicine. The practice told us that it would review patients prescribed this medicine and ensure the medicine was considered. Following our inspection, the practice confirmed they had taken action and no harm had been identified.

We saw evidence that the monitoring of patients prescribed disease-modifying anti-rheumatic drugs (DMARDs) was completed appropriately. These are medicines used to stop or slow down the damage caused by the progression of inflammatory disease. We identified 712 patients in our searches who were prescribed ACE inhibitors or Angiotensin II receptor blocker medicines (medicines that widen blood vessels and lower blood pressure) and reviewed 5 of these patients. We found that all of these patients had been followed up appropriately for their blood test monitoring.

During our site visit, we saw that emergency medicines were checked regularly and found them all to be in date. We saw that the practice had emergency equipment but only saw checks relating to June 2025 for the emergency oxygen supply and no record of checks for the defibrillator. The practice told us that it had updated its protocol and would now be documenting these checks. We found some out of date supplies in the drawers of the clinical rooms, including scissors, swabs and non-sterile dressings. The practice assured us that these supplies would not have been used and that it would conduct a thorough check of cupboards in all rooms and remove out of date items.

We noted that some Patient Group Directions (PGDs), which provide a legal framework that allows some health professionals to supply and/or administer medicines to a group of patients without them needing to see a prescriber, had not been consistently signed by both nursing staff and a relevant GP. The practice confirmed that it had rectified this issue whilst we were on site.