Updated 7 February 2024
We carried out an announced inspection at the Tulasi Medical Centre from the 13 to 26 March 2024. We carried out this assessment because the provider changed in July 2023, and this will be the first assessment of the new provider. This assessment reviews the key questions for safe and effective, a further assessment is planned for the review of the key questions caring, responsive and well led. The assessment included completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements). Reviewing patient records to identify issues and clarify actions taken by the provider. Requesting evidence from the provider, speaking with staff and visiting the main location and the two branches. During the assessment we found that: Some of the system, processes and policies were not fully effective. For example, significant events, referral, safeguarding, prioritisation of urgent appointments. The practice could not fully demonstrate how they assured the competence of staff employed in advanced clinical practice, for example, nurses, new GPs, and pharmacists. 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. Patients’ needs were mostly assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools. We found two breaches of good governance, because the systems to manage safety and safeguarding events were not fully effective. We found one breach of safe and effective staffing, because the practice could not fully demonstrate how they assured the competence of staff employed in advanced clinical practice, for example, nurses, new GPs, and pharmacists.