Olive Medical Practice

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• 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 inadequate.

The service was in breach of legal regulation in relation to good governance.

This service scored 36 (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 have a clear shared vision, strategy and culture.

The practice supplied us with their first business plan that had been put in place just before our assessment. This was a joint plan between them and another GP practice in a neighbouring town. The other practice had a separate NHS contract and CQC registration, and different patient demographics. The plan stated it would be shared with the Patient Participation Group (PPG), but no such group was in place. The plan was not fully completed and did not contain a strategy to develop the practice.

The practice supplied us with their mission statement and core values, and there was a practice vision on their website. There was no evidence that the practice took account of these or monitored that their vision and values were being met.

Staff told us they had access to policies and procedures but commented that there was no time allocated on induction to read these. The practice manager told us they were in the process of reviewing these. Staff told us that since the assessment was announced the practice had been busy putting policies in place and carrying out risk assessments.

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 provided us with their whistleblowing policy. The Freedom to Speak Up Guardian was the practice manager and all the staff we received feedback from were aware of this. The practice manager told us there was no delegated independent person outside the practice that staff could approach.

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 did not have clear responsibilities, roles, 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 practice worked closely with another GP practice in a neighbouring town. The majority of staff, including the practice manager and deputy manager, worked at both practices. Although the Registered Manager was the provider of the other GP practice, the other partners only worked at Olive Medical Practice. Policies were shared and significant events and complaints dealt with together. This led to some confusion around the roles, responsibilities and accountability arrangements for each separate entity.

Systems for identifying, capturing and managing risks and issues were ineffective. The system for managing complaints was not effective. The system for managing significant events was also not effective; not all incidents were being recorded and although staff told us incidents were discussed in meetings minutes about these were not always clear. The practice manager told us no minutes were kept for the clinical meetings because they did not have the capacity to supply a staff minute-taker.

There was no effective system for managing environmental risks. Required actions had not been completed following a fire risk assessment in 2024, and leaders were unaware that any action had been required. Risks relating to infection prevention and control and medicine management had also not been identified.

The practice did not have a Patient Participation Group (PPG). The practice manager told us told us there had not been one for a few years.

The practice reviewed external sources of feedback such as the National Patient Survey and the NHS Friends and Family Test but had not put an action plan in place when their results were below the national and local averages.

Healthwatch Blackburn with Darwen had carried out an Enter and View visit in June 2024. The practice had made some changes since they received their report, but some of the improvements they stated would be carried out had not been completed.

The practice did not focus on continuous learning, innovation and improvement across the organisation. Processes to ensure that learning was shared when there were incidents were not effective. We saw not all significant events were recorded or actioned appropriately as per the provider’s own policy.

We asked the practice to provide us with evidence that the quality of treatment and services had been monitored within the last 12 months, including 2 completed clinical audit cycles. The practice provided us with 2 clinical audits. Neither had been repeated to provide evidence of improvement, and 1 was undated.

The practice did not have a system of oversight or audit of clinical consultations, record keeping or prescribing for advanced care practitioners. The nurse manager was line-managed and previously appraised by a non-clinical manager.

Staff meetings took place but minutes, when they had been kept, did not contain a lot of detail to guide staff who had not been in attendance. Staff had commented on this.

We asked the Registered Manager about areas of innovation within the practice. They mentioned an idea but said it had not progressed as it involved a lot of work.