Todmorden Health Centre Also known as Pennine GP Alliance

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.