Olive Medical 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 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 inadequate.

The service was in breach of legal regulations in relation safe care and treatment and requirements in relation to workers.

This service scored 34 (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 did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The practice had a significant events policy. This gave examples of what should be recorded as significant events, including new cancer diagnoses, and events that had resulted in a complaint. None of these examples had been recorded as significant events. The policy did not state who was responsible for any aspect of significant event reporting. There was no system to monitor significant events to say how many there had been, at what stage any investigation was at or if any themes had been identified. The practice worked closely with a practice in a neighbouring area. Significant events for both practices were kept and dealt with together so there was no insight into what issues were specific to this practice.

We reviewed 4 significant events forms. These did not contain enough information to determine exactly what had happened, what action had been taken or was required, or if learning had been shared and embedded. For example, an incident about a needlestick injury did not make it clear who had been injured, or what the advice from Occupational Health had been, and an incident about a cold chain breach did not indicate what the result of the investigation was. One significant event had not identified a possible data breach as a result of an error. In addition, we were told about a serious incident in the practice a month prior to our assessment. Although this had been discussed in a meeting of the GP partners, no significant event form had been completed and there was no monitoring of actions that were required to stop the incident being repeated.

Significant events were discussed at the partners’ meetings, but minutes did not clearly indicate outcomes. Some staff, including clinicians, told us they were not invited to meetings where significant events were discussed. The practice manager told us they were informed about them if they were directly involved. We reviewed minutes of administrative and reception meetings from November 2024. No significant events had been discussed.

The practice worked with a range of healthcare services to establish and maintain safe, effective systems of care for patients. Clinicians followed established care pathways for diagnosis, treatment, and referral to specialist services. Referrals to secondary care, including urgent referrals for suspected cancer, were managed promptly and appropriately followed up. Communications from secondary care, such as discharge summaries, were processed efficiently to ensure continuity of care. There was a system for processing information relating to new patients, including the summarising of new patient notes. There were protocols in place for managing incoming correspondence into the patient’s medical records. The clinical team reviewed all patient correspondence, and our review of patient records showed that all tasks had been acted upon. However, many of the systems, such as those managing infection prevention and control, and building safety, were not effective, putting people at risk.

The practice worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Although there were systems, processes and procedures in place relating to safeguarding matters and concerns, the safeguarding of people with a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision was not considered. The practice was unable to identify any patients with a DNACPR decision in place. They told us they did complete DNACPR decisions but did not code them in a way that could identify them. There was therefore no evidence that a person's wishes were upheld and there was no discrimination in decision making.

Systems, processes and procedures were in place relating to safeguarding matters and concerns. Policies and procedures were reviewed and up to date and were aligned with other local safeguarding teams. Staff were aware of how to identify, report, and take action for safeguarding concerns. Safeguarding alerts were added to the clinical record system when relevant, ensuring that all team members were aware of ongoing concerns and could act accordingly. The service had a designated lead for safeguarding adults at risk and children and staff were aware of this. Partners and staff were trained to appropriate levels for their role.

The practice tried to work with people to understand and manage risks through a holistic approach. It encouraged patients to attend for health screening. The practice told us parents of children who had not attended for childhood immunisations and people who had not attended for cancer screening, were followed up and further encouraged to attend. However, the impact of this contact was not evidenced. The last verified data showed that the practice was below the minimum uptake rate for cervical screening and childhood vaccinations. Patients who were prescribed high risk medicines were not always called for regular checks.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The practice 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 practice manager had completed a risk assessment form for all rooms in September 2024. These did not assess or identify risks for the areas. They detailed hazards, and an overall risk rating was calculated. These had been incorrectly calculated. They had also not been accurately updated. The previous practice manager, who left prior to September 2024, was noted as being responsible for monitoring some updates. The completed forms were generic; the same 6 hazards were detailed for all rooms and were often not relevant. For example, machinery, including guillotines, scissors and items with sharp edges, high shelving, and temporary storage of materials, were detailed for all rooms, including the reception area, staff kitchen and clinical rooms. There was no risk assessment for areas such as the entrance, corridors or patient toilet.

The practice had a health and safety policy. This contained no details of any checks or risk assessments that should be undertaken. It named staff who were responsible for various aspects of safety, for example training and first aid. However, staff told us various roles had only been allocated after we announced our assessment of the practice, and one of the staff members listed had not been in post when the policy was last recorded as being reviewed.

The practice manager told us there were 2 fire wardens at the practice, and although they both also worked at another GP practice they said there was always 1 based at Olive Medical Practice. We asked for training information for fire wardens and were told no staff member had been trained.

The practice manager told us they were putting together a fire folder; this was not in place when we arrived for our site visit. The practice had a fire risk assessment checklist. The practice manager told us they carried out informal checks only for most of the hazards listed. We asked for evidence that the fire alarm system and emergency lighting was tested regularly. They had last been recorded as being checked on 17 May 2024. The practice manager told us they would improve. A fire evacuation had taken place the week prior to our assessment. The practice acknowledged that staff had not evacuated the practice in a timely manner and said they would repeat this. There was no record of any previous fire evacuation. The person named on the fire safety policy as being responsible for fire evacuation drills was the previous practice manager who no longer worked at the practice.

An external company had carried out a fire risk assessment in April 2024. The practice manager told us this had been repeated recently but the report had not yet been received. The 2024 report highlighted that fire drills had not been completed and should be carried out at least twice a year. It also highlighted that work was required at the rear fire exit. This had not been carried out. Required checks were listed. However, although some were being carried out and recorded in April 2024, there was no record for some checks, and other checks had been discontinued.

There was a business continuity plan in place. This was a joint plan for 2 separate practices. Although it was recorded that it had been updated in April 2025, information was not accurate. For example, it referred to Olive Medical Practice as being a branch surgery that people could contact should the practice be unavailable.

The practice 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.

The practice provided us with their recruitment policy. The policy did not give enough information to guide managers about the checks required for new staff members.

We checked the information held for a selection of 8 staff. The required information was only available for 6 of the 8. A Disclosure and Barring Service (DBS) check was not held for all clinical staff. Where a DBS check had disclosed a criminal record, the practice did not consider or assess if any risks were posed by the staff member. Evidence of staff member’s satisfactory conduct in previous employment concerned with the provision of services relating to health or social care, or children or vulnerable adults was not routinely considered or sought. They did not ask for reasons for leaving previous jobs with children or vulnerable adults. They did not hold a full employment history for all staff.

The practice had not carried out Right to Work checks for staff using a non-UK passport.

The practice manager told us new staff had an induction to the building, but not to their role. Most permanent staff had had a recent appraisal, and training was up to date.

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

The lead role for infection prevention and control (IPC) had been allocated the week prior to our inspection. The practice manager carried out an IPC audit in January 2024, and they told us it had not been repeated since. The IPC policy stated it would be an annual audit. The audit stated there was a daily and weekly cleaning specification, kept in the storeroom and completed by the housekeeper. During the site visit we asked for this and were told it did not exist. The practice manager told us they had not carried out a hand hygiene audit.

There was a cleaning checklist for each room, and the housekeeper ticked when area had been cleaned or checked. Not all areas were cleaned daily, and there were no instructions to state the frequency cleaning was required. Some areas were dirty and had not been recently cleaned, even though the checklist had been ticked. For example, skirting boards, scales and height measures in clinical consultation rooms were visibly dirty.

The infection prevention and control policy stated that training for all staff would be repeated annually. This did not happen.

The practice did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The practice had a significant events policy. This gave examples of what should be recorded as significant events, including new cancer diagnoses, and events that had resulted in a complaint. None of these examples had been recorded as significant events. The policy did not state who was responsible for any aspect of significant event reporting. There was no system to monitor significant events to say how many there had been, at what stage any investigation was at or if any themes had been identified. The practice worked closely with a practice in a neighbouring area. Significant events for both practices were kept and dealt with together so there was no insight into what issues were specific to this practice.

We reviewed 4 significant events forms. These did not contain enough information to determine exactly what had happened, what action had been taken or was required, or if learning had been shared and embedded. For example, an incident about a needlestick injury did not make it clear who had been injured, or what the advice from Occupational Health had been, and an incident about a cold chain breach did not indicate what the result of the investigation was. One significant event had not identified a possible data breach as a result of an error. In addition, we were told about a serious incident in the practice a month prior to our assessment. Although this had been discussed in a meeting of the GP partners, no significant event form had been completed and there was no monitoring of actions that were required to stop the incident being repeated.

Significant events were discussed at the partners’ meetings, but minutes did not clearly indicate outcomes. Some staff, including clinicians, told us they were not invited to meetings where significant events were discussed. The practice manager told us they were informed about them if they were directly involved. We reviewed minutes of administrative and reception meetings from November 2024. No significant events had been discussed.