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Review carried out on 14 February 2020

During an annual regulatory review

We reviewed the information available to us about Waverley PMS on 14 February 2020. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 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

Inspection carried out on 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

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

Inspection carried out on 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