Waverley PMS

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• 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 assessed a total of 4 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the January 2019 inspection, which was good. Our rating for this key question is requires improvement. We found that staff could describe the process for incident reporting however we did not see evidence of a formal process for sharing learning from significant events and complaints. Not all staff had completed required learning. Not all staff had the appropriate recruitment checks completed before commencing work at the practice. Infection prevention and control risk assessments had not been completed since 2017. Patients did not always receive the required monitoring tests for their prescribed medicines. Safety alerts were not effectively communicated or acted upon. The provider did not stock all expected emergency medicines and equipment, and did not effectively monitor the stock of these items.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was information on the practice website advising patients how to make a complaint via telephone, email or in person. There was a link on the practice website to the friends and family test, where patients could leave anonymous feedback.

Staff were able to describe the process for complaints and recording of significant events. We were told there were meetings where complaints and significant events were discussed and the minutes of these were available on the shared drive. However, when we reviewed practice meeting minutes there was no evidence to indicate complaints and significant events were discussed nor were these areas listed as standard agenda items. Staff knew how to find the incident reporting policy and were able to direct patients to enable them to make a complaint.

There were complaints and incident reporting policies. We reviewed the practice’s complaints log and found information of each complaint was recorded, however there was no clear evidence that this information was disseminated to practice staff. For example, we did not see evidence of discussion of complaints in practice meetings, nor did we see evidence of a review of themes of complaints to gain further insight.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Patients didn’t raise any concerns regarding safe and effective staffing. However, our findings meant that we were not assured all staff members had completed required training or that were recruitment processes were effective in ensuring patients always received safe and effective care.

Staff told us they were not always given protected time to complete required training and on occasion would need to complete training in their own time.

We reviewed the training and recruitment records of 4 staff members. We found several gaps in the training records of 3 staff members. There was no evidence that: • Two clinical staff had completed basic life support training in the last 12 months. • Two staff members had completed fire safety training. • Three staff members had completed safeguarding children training at a level appropriate to their role. • Two staff members had completed safeguarding adults training at a level appropriate to their role. • One member of staff had completed training in infection, prevention and control, mental capacity act, information governance, or equality and diversity. Following our site visit the provider shared evidence that 2 staff members had now completed all required training, some of the training was completed prior to our site visit and some completed after our site visit. We saw evidence that the other member of staff had completed some training, however we were not provided with records of basic life support, safeguarding children, safeguarding adults, or information governance training. We also found incomplete recruitment records. Of the 4 records viewed, there was no evidence that immunisation data had been collected for 3 staff members. In addition to this, one staff record did not include a completed induction checklist or appraisal. Another record didn’t include a signed contract, photo identification, Disclosure and Barring Services (DBS) check, induction checklist, or appraisal. Following our site visit the provider shared evidence of a signed contract and photo identification for one staff member. We were provided with a DBS check for one staff member; however this was not in a legible format. We were also provided with some immunisation data; however this did not include all vaccinations appropriate for the staff members’ roles. We were not provided with evidence of the remaining documents that were not seen at our site visit.

We found no concerns relating to people’s experience of infection prevention and control.

Staff provided us with details of an infection prevention and control (IPC) risk assessment completed in 2017. We asked, but were not provided with, evidence of a IPC risk assessment completed more recently. We saw evidence that the provider had completed an IPC audit in 2024.

We found appropriate signage, for example regarding handwashing, throughout the premises. We observed the premises at the main site to be clean and tidy. We found the toilet facilities at the branch site to be in a poor state of repair. For example there was a broken toilet seat and noticeable cracks in the paint. Clinical rooms at both sites appeared clean and well-maintained.

Records of staff immunisation did not show that all staff had been immunised according to best practice guidance. As part of our assessment we looked at the recruitment records of 4 staff members. The records of one clinical member of staff and one non-clinical member of staff did not include details of their immunisation status. After our assessment the provider showed us evidence of measles, mumps, and rubella immunity (but not tetanus, diphtheria, polio, or hepatitis B) for one member of staff. For the other member of staff we received evidence of tetanus, diphtheria, and polio immunity (but not measles, mumps, or rubella).

The findings from our clinical searches showed that patients’ medicines were not always managed in line with national guidance. For example, patients did not always receive the necessary monitoring tests or medicine reviews, nor were they always advised of associated risks of their prescribed medicines.

We shared our findings from the clinical searches with leaders at the practice. Staff were unaware of the concerns raised, prior to our clinical searches being carried out. Following our assessment the provider shared an action plan which detailed how they planned to address the concerns found.

There was a defibrillator held at each site, however neither had a working battery. Staff at the practice told us the defibrillator batteries at both sites had expired the week before our site visit. The following medicines were not found at either site; diclofenac intramuscular injection; glucagon or glucogel; buccal midazolam or rectal diazepam; or opiates. In addition to this the following medicines were not found at the branch site; soluble aspirin; or dexamethasone or soluble prednisolone. There were no risk assessments to document the reasons the medicines weren’t stocked, nor was there evidence that documented checks of emergency medicines or equipment had taken place to ensure they remained present and in date. Following our assessment, the provider sent us photographic evidence that soluble aspirin, diclofenac intramuscular injection and glucose tablets had been purchased. The provider told us rectal diazepam had been ordered and opiates were not stocked as part of the practice’s emergency medicines. There was no evidence to show dexamethasone or soluble prednisolone had been purchased nor was there a risk assessment to document the reasons for not holding this medicine. The provider also sent photographic evidence of 2 defibrillators and told us 1 defibrillator was fully functioning. The second defibrillator did not work and the provider planned to use 1 defibrillator across 2 sites (approximately 1.5 miles apart).

We reviewed the practice’s clinical system and found 500 pending results in the test results system. The provider told us these test results had been actioned and we saw evidence this was the case for all 3 test results we checked. However, we saw no formalised process for ensuring all test results were actioned and communicated with patients. The provider shared a copy of their medicines management policy which described procedures for responding to safety alerts, medicine reviews and repeat prescribing. However, our clinical searches did not show evidence of clear processes and procedures to ensure patients received appropriate reviews, information, and monitoring.

We reviewed 4 patients prescribed a medicine used to treat arthritis. We found these patients had not received the required monitoring tests. We reviewed 2 patients prescribed a medicine used to treat mood disorders. We found these patients had not received the required monitoring tests. We reviewed the records of 5 patients prescribed a medicine used to treat depression with an associated MHRA alert. We found these patients had not been warned of the associated risks of this medicine as per the MHRA alert. We reviewed the records of 5 patients prescribed a medicine that is usually used to treat epilepsy. We found that 3 patients had not received a review of this medicine in the last 12 months. Another patient was prescribed a medicine with an associated safety alert. There was no evidence that this patient had been warned of the associated risks of this medicine nor had they been able to discuss treatment options with a healthcare professional. We reviewed the records of 5 patients who had medicine reviews. We found medicine reviews to be lacking in detail and did not include checks of monitoring arrangements, quantities, or usage; and did not include a conversation with the patient.