Tulasi Medical Centre

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• 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 overall as good, but we found the service was in breach of regulation 17 of the Health and Social Care Act 2008 because the systems to manage safety and safeguarding events were not fully effective. The practice was also in breach of regulation 18 of the Health and Social Care Act 2008 because the practice could not fully demonstrate how they assured the competence of staff employed in advanced clinical practice. At this assessment, found the service had addressed these breaches and had improved their systems to manage safety and safeguarding events, as well as systems to assure the competence of clinical staff.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At our last assessment, we identified that the systems in place for learning and making improvements from significant events was not always effective. During this assessment we found improvements.

The practice introduced measures and updated procedures to enhance their significant event analysis. They revised their template to ensure a structured approach to reviewing incidents and provided support to clinicians and staff in completing the analysis. We reviewed the practices’ significant event log and found that significant events were being accurately recorded, with follow-up investigations taking place. We were able to see evidence of sufficient recording of investigations carried out into clinical events.

Learning from incidents was fully documented and resulted in changes that reduced the risk of recurrence. A review of the practices’ policies showed information from the national NHS learn from patient safety events (LFPSE) was included. We were satisfied that lessons were being learned and that the practice was making continuous efforts to identify and embed good practice.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

In our last assessment, we found that the safeguarding system was not effective, as the practice could not demonstrate that a comprehensive review of safeguarding registers had been carried out. During this inspection we saw improvements.

The practice made changes to its safeguarding procedures and consolidated multiple registers into a single safeguarding register with more regular reviews. The practice continued to hold regular multi-disciplinary meetings with secondary care organisations and other external stakeholders. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures with continual training and coaching offered to clinical and non-clinical staff. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

We reviewed two adult safeguarding patients and two child safeguarding referrals and were satisfied appropriate safeguarding procedures had been followed. We were satisfied the practice were able to evidence a full review of their safeguarding register was conducted, and were able to see a culture of raising safeguarding concerns was encouraged.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

At our previous assessment, we identified a breach in safe and effective staffing because the practice could not fully demonstrate how they assured the competence of staff employed in advanced clinical roles. The practice was not adhering to its supervision policy, which required regular audits of clinical staff. During this inspection we found improvements.

The practice had implemented changes to strengthen their clinical governance and to ensure staff competence. These included updating the supervision policy to increase the frequency of audits, enhanced appraisal processes, and improving the reporting of trends and concerns during governance meetings.

We reviewed consultation audits and appraisals and found leaders were adhering to their updated supervision policy. For example, we saw evidence of audits being carried out every six months or more frequently if consultations were not up to standard. This included the auditing of all clinical staff, such as nurses.

We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.