Tulasi Medical Centre

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 have found two breaches of good governance, because the systems to manage safety and safeguarding events were not fully effective. The system in place to learn and make improvements from significant events was not always effective. The practice had not formally recorded the regular review of the safeguarding registers. The practice could not fully demonstrate how they assured the competence of staff employed in advanced clinical practice, for example, nurses, new GP, and pharmacists. The leaders and staff told us there was a system to ensure referrals to specialist services were documented, contained the required information and there was a system to monitor urgent and delays in referrals. Some of the practice policies did not reflect staff practices. There was a system for recording and acting on safety alerts. The practice had systems for the appropriate and safe use of medicines, including medicines optimisation. Appropriate standards of cleanliness and hygiene were mostly met.

This service scored 62 (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 registered to provide regulated activities with CQC in July 2023, therefore at the time of the assessment the national GP survey data for the provider had not been published. The practice had undertaken its own patient survey in February 2024, although no specific questions were asked about learning culture, the survey found 60 out of 74 patients described the experience of their last appointment as very or fairly good and 59 out of 74 found the receptionists very helpful or helpful. CQC did not speak to patients on the day of the assessment. CQC received patient feedback from 12 people from August 2023, all the comments were negative although there were no specific complaints regarding culture, two were regarding staff attitude. The practice had received 27 concerns/complaints from 1 December to 29 February 2024, there were no specific complaints regarding culture.

Leaders and staff told us they knew how to identify and report concerns, safety incidents and near misses both internally and externally. They were able to discuss evidence of some learning and dissemination of information. Leaders described a system for recording and acting on patient safety alerts. Staff told us that complaints were responded to promptly, discussed at governance meetings and lessons were learnt.

The system in place to learn and make improvements from significant events was not always effective. For example, we found that events were not always recorded on the significant events log and there was evidence of insufficient recording of investigations carried out into clinically significant event. Also, the learning and actions to prevent similar events from occurring in the future was not always fully documented. A review of the significant events policy found that it did not include information about the national NHS learn from patient safety events (LFPSE). As part of our inspection several sets of clinical record searches were undertaken by a CQC GP specialist advisor. These searches were visible to the practice. We reviewed five patient records who may have been affected by a Medicines and Healthcare products Regulatory Agency alert, and we found all had been informed of the side effects of the medicines. The practice had a complaint policy reviewed in October 2023 and a complaints log from 1 December 2023 to 29 February 2024, this showed the practice had responded to the complaints, learnt lessons and discussed the complaints at the governance meetings. The practice had a duty of candour policy which was last reviewed in December 2023.

The practice registered to provide regulated activities with CQC in July 2023, therefore at the time of the assessment the national GP survey data for the provider had not been published. The practice had undertaken its own patient survey in February 2024, the service did not question patients directly about pathways and transitions. CQC received patient feedback from 12 people from August 2023, all the comments were negative although there were no specific complaints regarding systems, pathways and transitions, 7 were regarding access to the appointments. The practice had received 27 concerns/complaints from 1 December to 29 February 2024, there were no specific complaints regarding pathways and transitions but 19 were regarding access to appointments.

The leaders and staff told us there was a system to ensure referrals to specialist services were documented, contained the required information and there was a system to monitor urgent referrals and any delays. Staff told us there was a documented approach to the management of test results and these were reviewed in a timely manner and there was appropriate clinical oversight of the results, including when reviewed by non-clinical staff. The leaders explained they had a dedicated member of staff to process information relating to new patients including the summarising of new patient notes. Also, they had shared care agreements in place for patients who were treated by secondary care.

The leaders submitted copies of Integrated care meetings for March 2024, these demonstrated working within a multidisciplinary team to discuss and improve outcomes for people with complex needs. The practice supported two nursing homes for older people, the managers at both the homes confirmed that staff attended the homes weekly, responded promptly to their requests, and they had good lines of communication with the practice. The leaders explained that they were working with Barking, Havering, and Redbridge safeguarding team to develop a procedure regarding the transition of children on the safeguarding registers when they reached 18 years. The local Integrated Care Board told us they were working with the practice to improve systems at the practice.

We reviewed the process for the monitoring of urgent two-week patient referrals to secondary care with the staff and leaders and found that the documentation to support this process was not completed accurately. The leaders agreed to review this. The practice had carried out an audit of urgent patient referrals to secondary care in October 2023, this found there were no delays in the referral process and staff had completed the correct referral form. The leaders submitted a referral policy reviewed in October 2023, we found this did not describe the safety netting protocol for urgent referrals. We reviewed the process for managing test results and found on the day of the inspection these had been dealt with promptly. The leaders submitted a protocol for workflow, emails, post and test results last reviewed in December 2023. The prescribing policy, last reviewed October 2023, included the process for shared care agreements with secondary care.

We could not collect the evidence to score this evidence category.

The practice had a safeguarding GP lead and an administrator who were allocated time to review patients where there were safeguarding concerns. Leaders told us they met every month with the health visitors to review any child safeguarding concerns, and they would hold extra multidisciplinary team meetings for patients with any specific concerns. Clinicians explained safeguarding patient concerns were discussed at clinical meetings. Partners explained they and staff were trained to appropriate levels for their role. The lead partner for safeguarding told us they regularly reviewed the patients identified as a safeguarding risk; however, at the time of our assessment, this was not fully documented.

The leaders explained that they were working with Barking, Havering, and Redbridge safeguarding team to develop a procedure regarding the transition of children on the safeguarding register when they reached 18 years. The safeguarding leads met monthly with the health visiting team, and we were provided with copies of the monthly minutes and observed the minutes were brief and failed to include the dates of any issues or any follow up of actions from previous meetings.

The practice had systems, practices, and processes to keep, people safe and safeguarded from abuse. However, the Safeguarding/Significant Events and Complaints Procedure flow chart did not have the sufficient detail to protect patients when potential safeguarding incidents were raised. A review of patient records found the practice had a system to highlight vulnerable adults and children to staff. However, at the time of the assessment the safeguarding register required updating and the practice could not evidence that a full review of the register had taken place, the leaders immediately agreed to review and improve their system. The leaders submitted safeguarding children’s and vulnerable adult’s policies and Northeast London primary care safeguarding handbook, which provided information for staff to follow to enable the safe response to a safeguarding concern. All staff had completed the appropriate level of children’s and adults safeguarding and prevent radicalisation training.

The practice registered to provide regulated activities with CQC in July 2023, therefore at the time of the assessment the national GP survey data for the provider had not been published. The practice had undertaken its own patient survey in February 2024, the service did not question patients directly about meeting patient needs in a way that is safe and supportive and enables them to do the things that matter to them. CQC received patient feedback from 12 people from August 2023, all the comments were negative although there was no specific complaints regarding safe and supportive care, 7 were regarding access to the appointments. The practice had received 27 concerns/complaints from 1 December to 29 February 2024, there were no specific complaints regarding safe and supportive care but 19 were regarding access to appointments.

Staff told us there was an effective approach to managing staff absences and busy periods. The practice used a workforce management platform that offered flexibility and adapted quickly to fluctuating demands. Receptionists told us the actions they would take if they encountered a deteriorating or acutely unwell patient. Leaders told us there were enough staff to provide appointments and prevent staff from working excessively. Staff described the induction system for temporary staff which was tailored to their role.

We observed the practice sites were equipped to respond to medical emergencies, including suspected sepsis. Staff had completed both sepsis trainings and all but two members of staff had completed basic life support training. The leaders submitted a prioritising patient at risk policy to enable receptionists to provide a consistent approach when a patient requested an urgent appointment which was last reviewed in October 2023, this did not include all areas of possible risk, such as acute abdominal pain, hearing loss over one-week, and acute headaches. The leaders submitted a protocol for staff to follow to manage a medical emergency, this did not have an implementation or review date.

The provider told us that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste. Staff explained any maintenance concerns were promptly responded to by the leaders.

We visited all the sites and saw Parasols and Ripple Road were well maintained by the provider and Ripple Road had been refurbished. We saw risk assessments were in place for fire, legionella and health and safety and staff had mostly responded to the action plans. Except for the cupboard under the stairs at Bennetts Close which contained combustible materials, which had been highlighted as a risk during the previous fire and health and safety risk assessments in 2023.

The practice had completed fire risk assessments, fire drills and emergency lighting checks for all sites and most actions had been marked as completed. The practice provided evidence of annual portable appliance testing, and calibration of equipment for all sites. However, we noted this did not include the vaccination fridges. Staff had completed fire and health and safety training.

The practice registered in July 2023, therefore at the time of the assessment the national GP survey data for the provider had not been published. The practice had undertaken its own patient survey in February 2024, the survey found 53 out of 74 patients described themselves very satisfied or satisfied of the experience at the practice and 55 patients stated they would recommend the practice and 59 out of 74 found the receptionists very helpful or helpful. CQC received patient feedback from 12 people from August 2023, and none of the complaints were specifically about safe or effective staffing. two were regarding staff attitude. The practice had received 27 concerns/complaints from 1 December to 29 February 2024, there were no specific complaints regarding safe and effective staffing. CQC did not speak to patients on the days of the assessment.

The leaders had oversight of mandatory training and provided information that demonstrated staff had completed the necessary mandatory training for their role. The leaders told us they had a system in place to review the consultations and ensure the competency of allied and clinical staff. However, they explained this was only carried out annually or when a member of staff commenced their employment, which would not have provided continued evidence of staff competency. The leaders also informed CQC they were also unable to provide evidence of scopes of clinical practice in place to ensure clinical staff worked within their limitations. Following the assessment the provider explained this was now in place. Staff had protected time for learning and development. The leaders explained staff had completed annual appraisals and submitted data to verify this. The leaders told us they had sufficient staff and met their NHS target to provide 110 appointments each week per 1,000 patients.

The practice submitted a supervision policy which was last reviewed in October 2023. This stated clinical supervision audit for the clinical staff would be carried out regularly. Any new staff commencing in the practice would have audits carried out at 3 months and the next cycle will be decided dependent on the review findings. All clinical staff would have 6 monthly audits and if any concerns were raised this was changed to 1 or 3 monthly supervisions. At the time of the assessment, we found this was not fully implemented. A review of the clinician’s consultation’s audits demonstrated they were carried out annually, most were completed prior to the new provider taking over the service, and there was limited evidence of feedback to the staff and a lack of reaudit where issues were found. One senior nurse told us they took the lead on supervising new nurses but there was no evidence of this being formally documented. We found recruitment checks were carried out in accordance with regulations (including for agency staff and locums). The leaders submitted a recruitment policy last reviewed December 2023.

We could not collect the evidence to score this evidence category.

The leaders explained that the senior practice nurse was the lead for infection prevention and control, and they carried out regular checks of all the premises.

We visited all sites and found appropriate standards of cleanliness and hygiene were mostly met however at the Bennetts Close site we noted the practice did not have a means for the people to dry their hands in the patient’s toilet, this was resolved at the time of the assessment.

The lead nurse had completed an infection prevention and control audit for each site in February 2024. The practice had acted on any issues identified in infection prevention and control audits. Staff had completed infection prevention and control training.

We could not collect the evidence to score this evidence category.

The leaders explained there was a process for monitoring patients’ health in relation to the use of medicines including high risk medicines (for example, warfarin, methotrexate and lithium) with appropriate monitoring and clinical review prior to prescribing. Staff told us they had a system in place to ensure the safe prescribing of the patient’s repeat medicines. Staff explained the systems they used to monitor the vaccines, emergency equipment and medicines. The practice had completed audits to monitor the prescribing of controlled drugs. At the time of the assessment, leaders said the practice had one independent prescriber, who only prescribed medicines for diabetes.

We saw staff ensured medicines were stored safely and securely with access restricted to authorised staff. Staff had the appropriate authorisations to administer medicines (including Patient Group Directions or Patient Specific Directions). There was a process for the safe handling of requests for repeat medicines and evidence of effective medicines reviews for patients on repeat medicines. Blank prescriptions were kept securely, but further monitoring was required to ensure they were in line with national guidance. The practice held appropriate emergency medicines, risk assessments were in place to determine the range of medicines held, and a system was in place to monitor stock levels and expiry dates. There was medical oxygen and a defibrillator at each site and systems to ensure these were regularly checked and fit for use. Vaccines were appropriately stored, monitored and transported in line with UKHSA guidance to ensure they remained safe and effective.

The leaders submitted the cold chain policy for vaccines; however, this did not include the date of implementation or review. The leaders submitted a prescribing policy last reviewed in October 2023, this provided clear information regarding clinical and non-clinical staffs responsibilities to ensure safe prescribing. The staff had completed an audit of their prescribing of high dose opioids and DFMs (hypnotics, gabapentinoids) in October 2023. This stated the staff had learnt from the audit, reviewed their systems, and had reviewed patients regularly. In addition, they had implemented a designated clinical lead for opioids. The leaders submitted evidence of a review of antibiotic prescribing, in 2023, this found out of 15 patients prescribed an antibiotic six were prescribed antibiotics which were not compliant with the present prescribing guidelines. The actions from the review were to discuss the findings at a clinical meeting, provide further training and carry out an annual review.

As part of our inspection a number of set clinical record searches were undertaken by a CQC GP specialist advisor. These searches were visible to the practice. We found that monitoring was mostly appropriate overall. The clinical searches found patients receiving high-risk medicine leflunomide were put on repeat prescriptions, recalled for tests as required by guidance, and the GP was responsible for checking the necessary tests were conducted prior to prescribing. The clinical searches identified 58 patients taking a high-risk medicine Aldosterone (A diuretics or "water pill" used for the treatment of high blood pressure or heart failure). We sampled 5 of 8 patients identified as possibly not having the correct monitoring and found one patient was overdue their monitoring. The clinical searches identified 379 patients taking pregabalin (used to treat epilepsy and anxiety and nerve pain). We sampled 5 of 176 patients identified as possibly not having the correct monitoring and found all five patients were overdue their monitoring. We found the practice had completed 640 annual medicine reviews in the last three months. We reviewed a sample of 5 and found one did not have sufficient information regarding the review in the patients record. The NHS Business Services Authority medicines data in January to December 2023 for the average daily quantity of hypnotics prescribed per specific therapeutic group were in line with the national average for prescribing, antibacterials co-amoxiclav, cephalosporins and quinolones, Nitrofurantoin, Pivmecillinam and Trimethoprim tablets prescribed for uncomplicated urinary tract infection and the total items prescribed of Pregabalin or Gabapentin per 1,000 patients was in line with the national average.