Dr A Bisarya

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating remains the same.

The service was in breach of legal regulation in relation safe care and treatment and fit and proper persons employed.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. All reported incidents were thoroughly investigated and recorded to evidence transparency and learning.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

The provider had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. All reported incidents were thoroughly investigated and recorded to evidence transparency and learning.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

A safeguarding handbook was in place and known to staff. However, the practice did not follow the handbook with regard to safer recruitment. Not all the required employment history and reference checks were carried out prior to employing a new staff member. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

The provider worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. People were advised on risks related to their condition and actions to take if their condition deteriorated

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The premises were well- maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

The provider did not always make sure there were enough qualified, skilled and experienced staff.

Safe recruiting practices were not followed. We checked the information held for a selection of staff. The practice told us that a Disclosure and Barring Service (DBS) check was obtained for all staff. Evidence of this was not seen during the inspection. However, following the inspection the provider informed us DBS information was kept for all staff in a secure system that they had used since 2021.

Required information was not always kept. Of the 4 staff files we examined in full, none included a full employment history, and there were some gaps in the information provided by staff. References had been provided from employers that had not been mentioned in CVs, and the practice manager told us they did not match the information provided on CVs with the information provided during interviews. Reasons for leaving previous jobs involving work with children or vulnerable adults had not been provided or requested. Evidence of conduct in previous employment concerned with the provision of services relating to health or social care had not been provided or sought in all cases.

We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. People were protected as much as possible from the risk of infection because the premises and equipment were kept clean and hygienic. The arrangements for managing waste, sharps and clinical specimens kept people safe. Staff vaccination was maintained in line with current UK Health and Security Agency (UKHSA) guidance, if relevant to their role. There was a system for the service to report infection-related concerns to the relevant agencies (e.g. notifiable diseases).

Infection prevention and control audits were carried out and reviewed, and actions taken where necessary.The latest audit had been carried out in March 2025, and this showed a high level of compliance.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The process for authorising nurses to administer certain medicines was not effective. None of the 6 Patient Group Directions (PGDs) we checked had been completed correctly. For 5, nurses had been added to them after the authorising manager had signed them, and 1 had not been authorised. Following the assessment, the Registered Manager told us they had reviewed all PGDs to ensure they were correct.

The practice had a healthcare assistant who administered vaccinations, but appropriate Patient Specific Directions (PSDs) were not in place. A list of people requiring certain vaccinations had been printed out, but information such as the dose frequency, the date of treatment and the date the treatment should end, and a signature of the prescriber, along with the date, was not kept. The Registered Manager told us they had put a new electronic system in place, but this had not started at the time of the assessment so evidence could not be provided.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring.