'Systemic failures' found at GP practice suspended by care regulator

Tulasi Medical Centre was rated 'inadequate' by the Care Quality Commission (CQC) overall and across all five of its main inspection criteria - the worst rating.

CQC's head of primary care service inspection, Andy Ford, said it will not lift the suspension "unless we are assured patients will receive safe and effective care and treatment".

The result represents a marked drop from the regulator's previous inspection in 2017, which rated the practice 'good' overall.

A spokesperson for Tulasi Medical Centre said it is working with NHS North East London and CQC to address the issues raised in the report "as quickly as possible".

The latest inspection took place in May and June and came after the regulator said it had received concerns the practice "may not have been ensuring patient safety".

The service's main site is in Bennett's Castle Lane, Dagenham, with other branches in Parsloes Avenue, Dagenham, and Ripple Road in Barking.

It serves around 20,600 patients in total, according to CQC.

In its inspection report, published earlier this month, the care regulator said it reviewed 70 patient records and found "nearly all these patients had not been followed up following receipt of abnormal test results".

Inspectors wrote: "There was inadequate oversight of test results. We saw further evidence that patients continued to be prescribed medication, including high risk medicines, without up to date blood test results when they required repeating."

They also found the repeat prescribing system at the practice "was not safe and placed patients at risk".

The Ripple Road branch is one of three Tulasi Medical Centre sites (Image: Google)

According to inspectors, patient treatment "was not regularly reviewed and updated".

The report said: "A review of 70 patient records of the practice on both days of the inspection evidenced systemic failures which exposed patients to a serious risk to their life, health or wellbeing.

"We found examples of unsafe care and, evidently, patients’ treatment and care was not regularly reviewed or updated and clinical staff failed to follow up risk to patient health and wellbeing."

Inspectors also discovered 31 patients identified as having potential missed diagnosis of diabetes.

The practice's systems for referrals to specialist services were called "inadequate" by CQC.

"We saw evidence that non-clinical staff had raised concerns in meetings that clinicians were not completing referral forms correctly by either not signing them or not ticking every relevant box.

"This appeared to occur on a regular basis and meant these referrals were being rejected by the hospital."

Blank prescriptions "were not kept securely and their use was not monitored in line with national guidance", inspectors added.

They reported seeing large batches stored in "several unlocked printers in unlocked rooms".

The inspection was made up of an unannounced visit to the service on May 25, followed by a remote review on June 15.

Before the May 25 visit, inspectors said they tried to contact the practice and were unsuccessful in getting through.

When attempting to use the practice's reports line, they wrote they were placed in a queue for 90 minutes before being disconnected.

They added: "Patients were not able to make appointments in a way which met their needs. Patients complained to CQC and told us that it was impossible for working patients to get an appointment."

Mr Ford said Tulasi Medical Centre patients were not getting care and treatment to standards "they had a right to expect".

“This included a lack of processes to keep people safe from poor care and abuse," he added.

“We also found people couldn’t always access care in a timely way, patient feedback was negative and medication reviews weren’t routinely carried out, which was putting people at risk."

Following the suspension, he said services from the practice's sites are being carried out "by another provider.”

A spokesperson for NHS North East London said it took immediate action to ensure patient safety after becoming aware of the concerns.

They added: "We are working closely with the practice to put in place a comprehensive action plan to address the issues raised as quickly as possible.

“As commissioners, patient safety is our utmost priority and arrangements have been made to ensure that all patients at Tulasi Medical Centre can continue to access safe, high quality GP services at their usual surgeries.

“We have sent in a team of experts specialising in care quality, safeguarding, medicines management and primary care to provide ongoing advice and support to the practice and take any actions required.

"An experienced management team will also be taking over the running of the practice temporarily while the necessary improvements are made.”