Tulasi Medical Centre

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 assessed the key questions for safe and effective. This is the first time under its current registration with CQC we have looked at the key question of well-led.

This service scored 75 (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. Leaders and staff were able to explain the values and aims of the practice and had contributed to the development of the practice vision and strategy.

Leaders and staff worked in collaboration to improve on shortfalls identified from the previous assessment and to meet breaches. For example, all staff members were able to explain the importance of significant event management and the important of referring incidents that may constitute a safeguarding concern.

Senior leaders demonstrated awareness of the local demographics and adapted services and access needs accordingly.

The practice had three sites and worked to ensure a shared vision and strategy was maintained across all. This included shared responsibility of management, clinical and administrative staff cross all sites to manage administrative and patient demand accordingly. Leaders were aware of increasing patient demand and implemented several changes to allow patients to access services.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively.

A staff survey conducted in 2024 showed that 82% of staff felt supported through emotionally demanding work and 89% of patients were given supportive feedback on the work they do. These results were reflected in the conversations we held with administrative and receptionist staff as the majority of staff told us leaders at the practice were approachable, visible and responded to any concerns raised.

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 were aware of how to raise concerns.

The service valued diversity in their workforce and there was a diverse set of staff members. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure staff were valued and staff had undertaken equality and diversity training.

There were clear responsibilities, roles, systems of accountability and good governance and leaders ensured they were all responsible for staff concerns and clinical safety. Leaders acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Since our last inspection, governance structures had been strengthened to ensure improved oversight on policies and procedures, such as safeguarding, significant event management and clinical supervision.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. This was reflected in the practices’ December 2024 staff survey, in which 95% of staff were satisfied on how clear their duties and responsibilities were.

Managers met with staff regularly to complete appraisals and performance reviews.

The practice established governance processes that were appropriate for their service. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff.

The service understood their duty to collaborate and work in partnership and staff spoken with during the assessment had knowledge of local services and were able to describe where they would signpost patients for further support. The practice worked closely with secondary care organisations to provide support and meet the needs of patients.

Leaders explained they held multidisciplinary team meetings to discuss and improve outcomes for people with complex needs.

Leaders told us and provided evidence of meeting minutes of discussions with secondary care organisations, such as district nurses, palliative care and health visitors. The practice also worked within their Primary Care Network (PCN) to offer extended access, and flu and covid vaccination programmes. The practice had an active Patient Participation Group (PPG) who met regularly with the practice management team. Changes were implemented because of discussions in PPG meetings, such as patients no longer having to queue outside in the mornings to book GP appointments. We spoke to two members of the PPG, who spoke positively about the practice team and stated leaders and staff were involved and listened to patients.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Significant events and complaints were used for learning and improvement. The practice reviewed consultation audits frequently to ensure consistency and quality of patient care. The practice used patient views to improve services, including through patient complaints, compliments and the patient participation group.

The practice had a quality improvement plan in place to help drive improvements in services, including ways of improving patient access and their appointment system.