Dr A Bisarya

Date of Assessment: 11 December 2025. Dr A Bisarya is a GP practice that delivers services to approximately 2900 patients under a contract held with NHS England. The National General Practice Profiles states that 97% of the practice population is White, 1% Asian,1% Mixed and 1% Black and Other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 4th decile (4 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

The practice was assessed in June 2025. It was rated good overall but the key question of safe was rated requires improvement. We found 2 breaches of regulation relating to safe care and treatment and fit and proper persons employed. We requested an action plan from the provider. This assessment was to check if the provider was now compliant with the regulations. We only assessed the key question of safe.

Since the last assessment, the practice had made improvements and is no longer in breach of the regulations.

Safe - The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

Date of Assessment: 2 June 2025 to 5 June 2025. Dr A Bisarya is a GP practice delivering services to 2900 patients under a contract held with NHS England. The National General Practice Profiles states that 97% of the practice population is White, 1% Asian,1% Mixed and 1% Black and Other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 4th decile (4 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

SAFE: Recruitment procedures were not safe; the provider did not carry out all the required checks or hold the required information. Nurses and healthcare assistants were not correctly authorised to administer medicines to people. The provider had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks identified were mitigated. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

EFFECTIVE: People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people and took decisions in people’s best interests where they did not have capacity.

CARING: People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.

RESPONSIVE: People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.

WELL-LED: Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback, were treated equally, and were free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

We found breaches of regulation in relation to safe care and treatment and fit and proper persons employed. We have asked the provider for an action plan in response to the concerns found at this assessment.