The Care Quality Commission
  • Doctor
  • Out of hours GP service

Todmorden Health Centre Also known as Pennine GP Alliance

Overall: Good read more about inspection ratings

Lower George Street, Todmorden, Lancashire, OL14 5RN (01706) 811100

Provided and run by:
Pennine GP Alliance

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Todmorden Health Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Todmorden Health Centre, you can give feedback on this service.

30 June 2022

During an inspection looking at part of the service

This service remains rated as Good overall and now good for providing well-led services. (Previous inspection June 2021 Good).

We carried out an announced focused inspection at Pennine GP Alliance to follow up on breaches of regulation identified at our previous inspection.

At the last comprehensive inspection on 23 June 2021, we rated the practice as Good overall and for four of the five key questions. We rated the practice Requires Improvement for providing well-led services. This was because:

  • There were gaps in recruitment documentation.
  • There were gaps in core training and frequency of training updates.
  • There were gaps in the business disruption and continuity plan and the process had not been practised.
  • Health and safety risk assessments of the providers service within the host GP practices, including fire evacuation, had not been undertaken.
  • There was insufficient oversight of premises and equipment facilities management undertaken by host GP practices.
  • Policies and procedures contained insufficient information and did not always reflect the provider’s procedures.

In addition, we told the provider they should make improvements in the following areas:

  • Implement a system to track and monitor prescription stationery used by the service.
  • Review the system to identify and record incidents and significant events to ensure all potential learning opportunities are captured to drive quality improvement.
  • Develop a system to monitor the process for seeking consent to ensure consent and decision-making is in line with legislation and guidance.
  • Improve and develop staff awareness of duty of candour and ensure all staff are aware of their responsibilities in relation to this.

We asked the provider to make improvements regarding the issues identified and submit an action. We checked these areas as part of this focused inspection and found these had been resolved.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Requesting evidence from the provider
  • A short site visit
  • Staff questionnaires sent to staff ahead of the inspection

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as Good for providing well-led services and for the service overall.

We found that the provider had:

  • Recruited a new chief executive officer and expanded the Board and management team since our last inspection, to improve management and governance oversight across the organisation.
  • A clear vision and strategy was in place, and was accessible to staff and patients.
  • Implemented an electronic management system which enabled them to record and monitor information including recruitment documentation, staff training, premises and policy documentation.
  • Reviewed and updated the business continuity plan.
  • Established records of premises and facilities documentation for each of the host locations.
  • Developed a comprehensive record of significant events and incidents which clearly outlined learning outcomes and action taken by the provider.

Whilst we found no breaches of regulations, the provider should:

  • Recruit an external Freedom to Speak Up Guardian and ensure all staff are aware of their contact details.
  • Conduct a fire evacuation during operational hours at each location.
  • Continue with plans to increase frequency of staff meetings and consider improving visibility of leadership and management team to improve staff engagement.
  • Improve communication mechanisms to ensure feedback from staff is responded to.

23 June 2021

During a routine inspection

We carried out an announced comprehensive inspection of the extended access service run by Pennine GP Alliance Limited at Todmorden Health Centre on 23 June 2021. Overall, the provider is rated as good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led – Requires Improvement

Why we carried out this inspection

This announced comprehensive inspection was the provider’s first inspection. We looked at the key questions safe, effective, caring, responsive and well-led.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Requesting evidence from the provider
  • A site visit

As part of this inspection we interviewed by video conferencing, the Operations Manager, a GP, two advanced nurse practitioners, two advanced clinical practitioners and two receptionists. On the day of the inspection we interviewed at the location the Registered Manager, the GP Clinical Lead and the Operations Manager. We also interviewed by telephone, a GP and an advanced clinical practitioner who were working remotely for the extended access service on the day of the inspection.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this provider as good overall and requires improvement for the key question well-led.

We found that:

  • The provider continued to contribute to the local health agenda and work in partnership with stakeholders to deliver patient care during the challenges of the past year with the COVID-19 pandemic.
  • There were gaps in the oversight of some systems and processes to demonstrate effective governance. In particular, there were gaps in staff recruitment documentation, staff training and frequency updates, oversight of premises and equipment at the host GP practices, health and safety risk assessment, including fire evacuation, business continuity planning and policies and procedures.
  • There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns.
  • Leaders reviewed the effectiveness and appropriateness of the care the service provided. They ensured that care and treatment was delivered according to evidence-based guidelines.
  • There was a programme of quality improvement, including clinical audit.
  • Staff had the skills, knowledge and experience to deliver effective care.
  • Staff involved and treated people with compassion, kindness, dignity and respect.
  • Leaders demonstrated they had the capacity and skills to deliver high-quality, sustainable care.
  • Patient feedback about the service had been positive.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Implement a system to track and monitor prescription stationery used by the service.
  • Review the system to identify and record incidents and significant events to ensure all potential learning opportunities are captured to drive quality improvement.
  • Develop a system to monitor the process for seeking consent to ensure consent and decision-making is in line with legislation and guidance.
  • Improve and develop staff awareness of duty of candour and ensure all staff are aware of their responsibilities in relation to this.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care