The Care Quality Commission
  • Doctor
  • GP practice

Dr A Bisarya

Overall: Good read more about inspection ratings

Sandy Lane Health Centre, Sandy Lane, Skelmersdale, Lancashire, WN8 8LA (01695) 736191

Provided and run by:
Dr Bisarya & Partner

All Inspections

12 October 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at Dr Bisarya on 10 & 12 October 2022. Overall, the practice is rated as good.

Safe - requires improvement

Effective - good

Caring – Not inspected

Responsive - Not inspected

Well-led - good

Following our previous inspection on 22 June 2016 the practice was rated good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Bisarya on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. This was a focused inspection that looked at the minimum requirement of the safe, effective and well-led key questions.

How we carried out the inspection.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included;

  • Conducting staff interviews using video conferencing.
  • 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.
  • A short site visit.

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 found that:

  • The practice had systems and processes in place to assure them that both patients and staff were safe in the working environment but were unable to demonstrate that these were always fully effective.
  • The practice had achieved a good standard of care delivery in the majority of areas. Those areas that were in need of further development were known by the practice, who had strived to address them within their agency to do so. Immunisations for children and breast screening where two such areas that the practice had attempted to address.
  • The practice had systems and processes in place covering all governance areas with varying degrees of effectiveness. Although we found some gaps, the practice systems had identified others and arrangements that were in place allowed the practice to adapt and respond to our concerns immediately.

The provider MUST:

  • Ensure care and treatment is provided in a safe way to patients.

The provider should:

  • Take steps to ensure that staff immunisation status is addressed and recorded.
  • Update processes for ensuring that asthma patients have a comprehensive review including prescribing data.
  • Take planned steps to improve upon immunisation and breast screening uptake data.
  • Action concerns identified by risk assessments in a timely manner.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

22/06/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr A Bisarya on 22 June 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. Significant events were investigated thoroughly and learning effectively implemented as a result.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients were overwhelmingly positive about their experiences at the practice and said they were treated with compassion, dignity and respect. They felt involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it very easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

We saw areas of outstanding practice:

  • The practice was proactive in liaising with secondary care providers in order to improve clinical communication channels and improve patient care. Evidence confirmed that changes had been made by local NHS Trusts to improve systems around feeding back results to local GP practices as a direct result. This meant that GPs received results in a more timely manner with more accurate information, resulting in patients being able to access the most appropriate treatment more quickly.

  • Two dieticians attended the practice each month to run clinics for the practice’s patients, one of whom was a specialist dietician for patients with diabetes.

The areas where the provider should make improvement are:

  • Ensure second cycle audits are completed in order to monitor changes and make sure improvements are maintained.

  • The practice should continue with its efforts to establish a patient participation group.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice