Waverley PMS

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed a total of 2 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 the provider’s governance processes were not always effective in the identification and management of risks.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff spoke positively about leaders in the practice, reporting that GPs and management were visible and approachable. Staff described the working environment and relationships between staff and managers as positive. Staff described the team as supportive and cohesive. We found that 2 of the 3 non-clinical staff members were unable to describe what the duty of candour entailed.

Staff were aware of their roles and responsibilities. There was a clear leadership structure in the practice. We found the processes for sharing information regarding complaints, significant events, safeguarding and safety alerts were not always effective. We did not see evidence of a formalised process for sharing information or concerns.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us they knew how to access policies and procedures. However, staff also told us they were not always given protected time to complete required training and on occasion would need to complete this in their own time.

Our assessment identified that improvements were required in relation to the governance, oversight and management of risks relating to: • Monitoring of patients with long term conditions. • Management of medicines requiring monitoring. • Safety alerts. • Medicine reviews. • Clinical audits. • Processes for the discussion and communication of significant events, complaints, safeguarding concerns or medicines safety alerts. • Management of test results. • Staff training. • Staff recruitment. • Infection prevention and control.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.