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Inspection Summary

Overall summary & rating


Updated 12 February 2019

We carried out an announced comprehensive at Waverley practice and the branch practice at Welling branch surgery on Thursday 10 January 2019 as part of our inspection programme.

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 have rated this practice as good overall and good for all population groups. (Previous rating October 2015 – Good)

At this inspection we found:

  • Feedback from patients about the staff, care and treatment was positive.
  • Patients appreciated the improvements in the appointment system and said it was easy to use. Patients reported that they were able to access care when they needed it.
  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services and participated in external groups to ensure they understood the local changes and challenges.
  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice recognised where systems and processes had worked well and improved their processes where appropriate.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Medicines, including high risk medicines and prescribing were effectively managed.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Staff had access to learning, improvement and involvement at all levels of the organisation.
  • Staff said the practice and branch were good places to work.

The areas where the provider should make improvements are:

  • Continue to monitor and address clinical performance. For example Quality Outcome Framework (QOF) scores, screening rates and consider alternative approaches to reach non engaged population.
  • Review the content and suitability of training to ensure it provides staff with the skills and knowledge of how to meet the needs of patients. For example, basic life support and when making best interest decisions to ensure they fully understand their roles and responsibilities related to best interests decision making.
  • Review how effective patients with psychosis are being coded (identified) on internal computer systems to ensure this patient group are correctly identified and supported.
  • Review systems to ensure patients diagnosed with a psychosis have a completed mental health care plan.
  • Consider increasing the clinical audit/quality improvement programmes.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Inspection areas










Checks on specific services

People with long term conditions


Families, children and young people


Older people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable