The Care Quality Commission
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  • GP practice

Waverley PMS

Overall: Good read more about inspection ratings

The Waverley Practice, 37 Waverley Crescent, Plumstead, London, SE18 7QU (020) 8319 7614

Provided and run by:
Waverley PMS

All Inspections

During an assessment under our new approach

Date of Assessment: 13 May 2026 to 18 May 2026. Waverley PMS is a GP practice and delivers service to approximately 4,524 patients under a contract held with NHS England. The National General Practice Profiles states that the ethnic make-up of the service is approximately 52% White, 21% Black, 17.3% Asian, 5.1% Mixed and 4.7% 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.

Since the last inspection, in March 2025, the practice had made improvements and is no longer in breach of regulation relating to safe care and treatment. Whilst the practice had also made improvements relating to good governance, we found breaches of this regulation at this inspection. We have asked the provider for an action plan in response to the concerns found at this assessment.

SAFE: There were processes to raise and investigate concerns. However, it was not clear that learning from such events was always shared with staff. Supervision of clinical staff was not always formally recorded. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. 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 made sure people understood their care and treatment to enable them to give informed consent.

WELL-LED: Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. There were some areas where the provider had failed to identify or assess the risk to staff and patients.

During an assessment under our new approach

We carried out an announced inspection on Waverley PMS on 10 and 11 March 2025. This was a responsive inspection to follow up on breaches of regulation found at a previous inspection in July 2024. Waverley PMS is an NHS GP practice located in South East London. At the time of our inspection there were approximately 4447 patients registered with the service.

The National General Practice Profiles states that the ethnic make-up of the practice area is 51.96% White, 20.96% Black, 17.3% Asian, 5.11% Mixed and 4.68% Other.

Information published by the Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 5th decile (5 out of 10). The lower the decile the more deprived the practice population is relative to others.

This inspection considered the demographics of 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.

We found breaches of regulation in relation to safe care and treatment and good governance. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.

During an assessment under our new approach

We carried out an announced assessment on Waverley PMS on 1 and 2 July 2024. Waverley PMS is an NHS GP practice located in South East London. At the time of our assessment, there were approximately 4400 people registered with the service. We conducted this assessment due to receiving information of concern. We assessed 12 quality statements across safe, effective, caring, responsive and well-led key questions and have combined the scores from these areas with scores from the previous inspection.

We found that processes and procedures did not always keep people safe. Patients with long term conditions were not always monitored in line with best practice guidance. Governance processes were not always effective in the identification and management of risk.

We found that patient feedback was mostly positive about the care received and access to appointments.

12 January 2024

During an inspection looking at part of the service

We undertook a targeted assessment of the responsive key question at Waverley PMS. The rating for the responsive key question is good. As the other key questions were not reviewed during this assessment, the rating of good will be carried forward from the previous inspection and the overall rating of the service will remain good

Safe - not inspected, rating of good carried forward from previous inspection.

Effective - not inspected, rating of good carried forward from previous inspection.

Caring - not inspected, rating of good carried forward from previous inspection.

Responsive – good.

Well-led - not inspected, rating of good carried forward from previous inspection.

Following our previous inspection on 10 January 2019 the practice was rated good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Waverley PMS on our website at www.cqc.org.uk

Why we carried out this assessment

We carried out a targeted assessment of the responsive key question. Targeted assessments enable us to focus on certain key questions to explore particular aspects of care.

We recognise the work that GP practices have been engaged in to continue to provide safe, quality care to the people they serve. We know colleagues are doing this while demand for general practice remains exceptionally high, with more appointments being provided than ever. In this challenging context, access to general practice remains a concern for people. Our strategy makes a commitment to deliver regulation driven by people’s needs and experiences of care. These assessments of the responsive key question include looking at what practices are doing innovatively to improve patient access to primary care and sharing this information to drive improvement.

How we carried out the assessment

This assessment was carried out without a site visit

This included:

  • Conducting staff interviews using video conferencing.
  • Requesting evidence from the provider.

Our findings

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 found that:

  • Patients could mostly access care and treatment in a timely way and patient satisfaction with access to the service had improved over the previous year.
  • The practice constantly monitored and reviewed the appointment system to ensure appointments were offered to meet patient demand.
  • Complaints were listened and responded to.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

10 January 2019

During a routine inspection

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

21 October 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 10 December 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breaches of regulation 9(1)(b)(iii) and regulation 11(a)(b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

We undertook this focussed inspection on 21 October 2015 to check that they had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements and also where additional improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Waverley PMS on our website at www.cqc.org.uk.

Overall the practice is rated as Good. Specifically, following the focussed inspection we found the practice to be good for providing safe services. As the practice was now found to be providing good services for safe, this affected the ratings for the population groups we inspect against. Therefore, it was also good for providing services for older people; people with long-term conditions; families, children and young people; working age people (including those recently retired and students); people whose circumstances make them vulnerable and people experiencing poor mental health (including people with dementia).

Our key findings across all the areas we inspected were as follows:

  • Systems and processes were in place to keep people safe. Staff had received updated training in safeguarding adults and children and newly recruited staff had training booked. Safeguarding processes were discussed at team meetings.
  • The practice had systems in place to be able to respond to a medical emergency. There was access to emergency equipment including oxygen and an Automated External Defibrillator (AED) and staff had received updated training in basic life support.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

10 December 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Dr Gupta and partners, (also known as Waverley PMS, is located in Plumstead in the London Borough of Greenwich in south-east London; and provides a general practice service to around 5,088 patients. The Waverley Practice operates a branch surgery at the Welling, 209 Wickham Street, Welling, Kent, DA16 3LP, which was not inspected as part of this inspection.

We carried out an announced comprehensive inspection on 10 December 2014.

Overall the practice is rated as Good. Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services. The practice required improvement for providing safe services.

We found the practice requires improvement in the care provided to people whose circumstances may make them vulnerable. We found the practice good at providing safe, effective, caring, responsive and well-led services for the other population groups we report on.

Our key findings were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.

• The practice had good facilities and was well equipped to treat patients and meet their needs.

• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

• There were systems in place for reporting, recording and monitoring significant events to help provide improved care.

• Staff shared best practice through internal arrangements and meetings and also by sharing knowledge and expertise with external consultants and other GP practices.

• Feedback from patients we spoke with during our inspection, in relation to their care and treatment was very positive. However patient feedback seen from the national GP survey 2012/2013 was mostly in the middle range.

• The practice has an active Patient Participation Group (PPG) and worked with them to improve the service. The practice had a strong focus on caring and on the provision of patient-centred care.

However, there were also areas of practice where the provider needs to make improvements.

The provider must:

  • Patients were at risk of harm because systems and processes were not in place to keep them safe. Staff did not know how to recognise or identify what constituted a safeguarding concern and had not been trained in adult safeguarding.
  • Ensure the availability of medical oxygen for use in the event of medical emergencies.

The provider should:

  • Ensure availability of an Automated External Defibrillator (AED) or undertake a risk assessment if a decision is made to not have an AED on-site.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice