Dr Olajide Ijaola Also known as Riverside Surgery Tamworth

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.
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 good governance. We have taken action in response to these breaches of regulation.

This service scored 57 (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 had a shared vision, strategy and culture.

The practice had a mission statement in place and staff were aware of this. Leaders told us that the local area is growing in population and to accommodate for this growth they would like to expand their service.

Not all leaders understood the context in which the service delivered care, treatment and support.

Staff reported that practice leaders were approachable and responsive to concerns raised. We observed that the leadership team collaborated effectively with other practices within the Primary Care Network.

However, there were areas where leadership responsibilities lacked clarity. For example: The management of blank prescriptions was not consistently aligned with safe practice standards. Systems for managing complaints and significant events required strengthening to ensure full compliance with policy, robust investigation, and the identification and implementation of learning and corrective actions. The practice demonstrated a lack of awareness regarding its obligations in relation to Patient Specific Directions (PSDs). There was ambiguity surrounding the processes for recording and evidencing clinical supervision.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff told us they felt they could raise concerns if necessary and knew where to look for information around accessing Freedom to speak up.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff told us the practice was supportive, considerate, and responsive to their needs. While we did not see a standalone equality and diversity policy, the practice had an Accessible Information Standard policy underpinned by equality and diversity principles, and records showed staff had completed equality and diversity training.

The service did not have clear systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The governance framework was ineffective in proactively identifying risks or implementing measures to address areas that required strengthening.

The provider had not displayed their Care Quality Commission (CQC) rating within the practice premises, as required by legislation. Upon enquiry, leaders indicated they were unaware of this statutory obligation. Leaders subsequently ensured the rating was displayed before the inspection team concluded the visit.

Policies and procedures were in place; however, leaders did not consistently adhere to them, particularly in areas such as staff recruitment.

The service operated with a small team and had defined responsibilities. However, we identified significant gaps in governance and oversight. Specifically, deficiencies were noted in systems and processes, including recruitment checks, monitoring of the cold-chain, infection prevention and control audits, and patient triage protocols. A lack of monitoring of some patient recalls, and missing risk assessments for emergency medicines and equipment not held by the practice.

The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The practice collaborated with some services; however, where collaboration was lacking, such as in safeguarding, information and learning were not shared to support improvement.

The practice did not have a Patient Reference Group. Leaders told us they would like one, however they were experiencing difficulties setting one up. There was no information from the practice about patient feedback and how this could drive improvement.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The practice informed us that they were going to expand the capacity of clinical rooms within the building. However, we saw no documented plans in place as to evidence when or how this would be achieved.

We found that there were some missed opportunities for learning and improvement within our clinical searches and the governance system findings.

The provider felt that due to the size of the practice they offered a better standard of continuity of care.