We carried out an unannounced inspection at Tulasi Medical Centre on 25 May 2022, followed by a remote review on 15 June 2022. Overall, the practice is rated as Inadequate.
Safe - Inadequate
Effective - Inadequate
Caring - Inadequate
Responsive - Inadequate
Well-led - Inadequate
Following our previous inspection on 22 June 2017, the practice was rated good overall but required improvement in safe care and treatment. The practice was found in breach of Regulation 12 of the Health and Social Care Act Regulations 2014. A follow up inspection for the safe key question was carried out on 10 May 2018 and the practice was rated good in the safe key question.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Tulasi Medical Centre on our website at www.cqc.org.uk
We carried out this inspection in May and June 2022 in response to concerns raised directly with CQC. This related to safety systems and processes and governance of the practice. In response to these concerns, we initially carried out an unannounced site visit inspection on 25 May 2022, followed by a remote clinical records review on 15 June 2022 and further evidence gathering on 21 June 2022.
This report covers our findings in relation to both the review and inspection.
How we carried out the inspection/review
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic and in order to reduce risk, we have conducted our inspections differently.
This inspection and subsequent remote review was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing and via telephone
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- An inspection site visit of the main site and one branch surgery
Our findings
We based our judgement of the quality of care at this service on a combination of:
- what we found when we inspected
- information from our ongoing monitoring of data about services and
- information from the provider, patients, the public and other organisations.
We have rated this practice as Inadequate overall
We found that:
- The practice did not have adequate systems, practices and processes to keep people safe and safeguarded from abuse.
- There were gaps in systems to assess, monitor and manage risks to patient safety.
- Patients’ needs were not assessed and care and treatment was not delivered in line with current legislation.
- The practice did not have a comprehensive programme of quality improvement activity.
- The practice was unable to demonstrate that staff had the skills, knowledge and experience to carry out their roles.
- Staff did not always work effectively together and with other organisations to deliver effective care and treatment.
- Staff were not consistent and proactive in helping patients to live healthier lives.
- The practice demonstrated that it always obtained consent to care and treatment in line with legislation and guidance but this required improvement.
- Staff did not always treat patients with kindness, respect and compassion. Feedback from patients was negative about the way staff treated people.
- Services did not always meet patients’ needs.
- People were not able to access care and treatment in a timely way.
- Leaders could not demonstrate that they had the capacity and skills to deliver high quality sustainable care.
- The overall governance arrangements were inadequate.
The areas where the provider must make improvements are:
- Ensure that care and treatment is provided in a safe way.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
On 22 June 2022, Tulasi Medical Centre was issued with an urgent notice to suspend their registration as a service provider in respect of regulated activities. This notice was served under Section 31 of the Health and Social Care Act 2008. This notice of urgent suspension of their registration was given because we believe that a person will or may be exposed to the risk of harm if we do not take this action.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care