Dr Olajide Ijaola Also known as Riverside Surgery Tamworth

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 looked for evidence that people were protected from abuse and avoidable harm.
At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement.
The service was in breach of legal regulation in relation to safe care and treatment and fit and proper persons employed. We have taken action in response to these breaches of regulation.

This service scored 41 (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 investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

We found that learning events were not collated, limiting the ability to identify trends or discuss them in meetings. Although processes for reporting incidents, near misses and safety events existed, they were not always effective; some incidents were not reported, and documentation often lacked detail, including root cause analysis. Opportunities to raise and investigate significant events were missed, and incidents were not always thoroughly reviewed.

One written complaint had been responded to, but not in line with the provider’s policy, and there was no system to record or investigate complaints.

Staff reported an open culture where safety was prioritised, and said managers encouraged them to raise concerns when things went wrong.

Systems were not embedded to prevent delays in managing tests results. The service worked with people and healthcare partners to establish and maintain safe systems of care.

The provider informed us that a backlog of test results had developed, which they anticipated would be cleared promptly. During our inspection, the provider presented evidence confirming that the backlog had been resolved. The provider informed us that they had recently engaged a new clinician. However, there was no robust or clearly documented plan in place to prevent similar delays from occurring in the future, and the new clinician had not yet been fully integrated into their role within the practice.

There were systems in place for processing information relating to new patients. The service worked with other providers 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.

Safeguarding policies were in place, with the majority of staff trained in safeguarding procedures. The practice did not maintain a list of vulnerable people and did not have processes in place to ensure this was accurate and up to date. Leaders told us there were processes in place to follow up children who did not attend their appointment.

The service did not have all the recommended emergency equipment and medicine in place.

The provider had not undertaken a local risk assessment to determine the required emergency medicines to be held within the practice. Not all the recommended emergency equipment and medicines were available, nor had there been any documented steps taken to mitigate the risk of not having these items. Following on from our inspection the provider has sent us evidence that they now have this equipment and medicine in place. Staff could recognise a deteriorating patient and knew of action to take. People were advised on risks related to their condition and actions to take if their condition deteriorated. There was guidance for non-clinical staff on signposting patients to the appropriate clinician; however, it lacked detailed advice in key areas, including how to identify red-flag symptoms such as those associated with a stroke.

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.

Contracts were in place to ensure the premises were adequately maintained. A health and safety risk assessment had been completed; however, no actions had been identified as a result. Looped blind cords were not always secured throughout the building in line with national safety alerts. We highlighted this to leaders, who have since assured us that all blinds now meet current safety standards.

A recent fire safety inspection had also been carried out, which identified several actions that needed to be addressed. Some of the required completion dates for these actions had already passed. We raised this with the provider, and they have since confirmed that all outstanding actions have now been completed.

Safe recruitment practices were not always followed. We found a lack of appropriate recruitment records, and they did not always make sure staff received effective supervision.

There were a range of clinical and non-clinical roles within the practice. Leaders told us they were actively recruiting for both types of roles and had recently appointed a clinical pharmacist.
However, we found that safe recruitment practices were not always followed. Recruitment records were incomplete, and there was no documented evidence showing how risks arising from these gaps had been assessed or mitigated.

The provider told us they had systems in place, such as regular audit and clinical supervision, to assure themselves that non-medical prescribers were capable, supported and competent. However, when asked, they were unable to provide any evidence to support this.

Staff told us they had received training, and training records we reviewed confirmed this. However, the records contained gaps, and there was no system in place to identify or address these training needs.

Staff vaccinations were not maintained in line with current UK Health Security Agency (UKHSA) guidance where relevant to their roles.

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.

The practice had an identified lead for infection prevention and control (IPC), and staff had received IPC training. Cleaning schedules had recently been put in place and were being followed; however, only the current week’s completed records were available for review. We also observed mop heads stored incorrectly.

An IPC audit had recently been completed, and an action plan was in place to address identified issues. However, the audit had not identified that purple lidded sharps bins, required for the safe disposal of cytotoxic waste, were not available in the practice nurse’s room. The practice confirmed that 3 cytotoxic medicines were in use and acknowledged the requirement for the correct sharps bins.

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

Our clinical searches found 71 people had been coded as having a medication review in the last 3 months out of 2406. We reviewed 5 records and found 1 to be satisfactory. Of the other records reviewed, medication review codes had been entered when there was no evidence to demonstrate all medicines had been reviewed to ensure it was safe and appropriate to continue prescribing them.

For people who were prescribed non-steroid anti-inflammatory drugs, our clinical searches found out of 72 people there was a potential of 26 people who were not on appropriate gastroprotection. We sampled 5 records and found none of these people had been prescribed appropriate medicines and required a medicines review.

Nurses had the appropriate authorisations to administer medicines. However, patient specific directions (PSD), a written or electronic instruction from a qualified prescriber (such as a doctor) authorising a non-prescribing healthcare professional to administer a specific medicine to a named patient, were not in place. The provider confirmed that flu vaccines had been administered by a non-prescribing healthcare professional without the required PSDs.

We identified that prescription stationery was not stored securely, and there were no systems in place to monitor or track prescription stationery throughout the practice. This was highlighted as an area of concern at our previous inspection. This did not comply with national guidance, which requires organisations holding prescription forms to ensure their secure management and use.

Cold-chain monitoring for the vaccine refrigerator was not consistently robust. Temperature records indicated a potential cold-chain breach, with the refrigerator showing a sustained recorded temperature of 13.5°C from July through the end of October 2025. A process was not in place to investigate whether this was a genuine breach until November 2025. A staff member responsible for checking the fridge temperatures was not aware of the manufacture’s recommended temperature range in which the vaccines were required to be stored.

Although a data logger was in use, its readings were transmitted directly to a staff member’s personal mobile device. As a result, the practice did not have access to monitoring data when that individual was not on site. We were advised that the practice is in the process of reconfiguring the system so that data will be transmitted directly to a practice-owned device or central system.

The practice had undertaken some clinical audits, however the impact how this had improved care and treatment was unclear.