Waverley PMS

On this page

• 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 looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating remains the same.

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.

There were processes to review and discuss significant events, incidents and complaints. We saw evidence that meetings were held where significant events and complaints were discussed with clinical staff members. The provider told us that the minutes from these meetings were shared with non-clinical staff members. Staff told us incidents were shared with them but were unable to give a specific example of a recent significant event. Therefore, we could not be assured that learning from such events was identified or embedded to reduce the risk of harm to patients in the future.

Complaints were recorded and responded to; in most cases this was done verbally. We reviewed written responses to complaints and found these did not always include information regarding the Parliamentary and Health Services Ombudsman (PHSO). (Patients are able to contact the PHSO if they are not satisfied with the practice’s response to their complaint). Therefore, we were not assured that the right to complain to the PHSO was made clear to patients complaining about the service.

Following our site visit the provider sent us evidence that a briefing document had been shared with all staff to reinforce what constitutes a significant event, recent examples of significant events in the practice, and how to raise concerns. The provider also sent us a complaint response template they plan to use in the future, which included reference to the PHSO.

Patients felt supported to raise concerns and felt staff treated them with compassion and understanding. We spoke to patients who felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong, and staff felt there was an open culture.

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.

At our last inspection in March 2025, we found Disclosure and Barring Service (DBS) checks were not carried out in line with the practice’s policy. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable. We also found that staff files did not always contain details of staff members’ immunisation status. At this inspection in May 2026, we found no evidence of diphtheria, tetanus or polio immunisation for 2 non-clinical staff, nor was there an assessment of the risk to staff and patients if the staff in the practice did not have these immunisations. Therefore, there was a potential risk to staff and patients. DBS checks were carried out in line with the practice’s policy.

The practice provided us with risk assessments completed following our site visit to accompany the decision of the 2 non-clinical staff identified to not have the diphtheria, tetanus and polio vaccinations.

At our last inspection in March 2025, we found not all staff had completed training relevant to their role. At this inspection in May 2026, we found one member of clinical staff had completed safeguarding children training to level 2, where level 3 was appropriate for their role. We were sent evidence that level 3 safeguarding children training had been completed following our site visit. We reviewed a further 4 staff files which showed staff had completed training appropriate to their role.

The provider told us they supervised staff in clinical roles; however, this supervision was not formally recorded. Staff we spoke to confirmed supervision did take place and this was not recorded. We were told the supervision included review of patient records and discussion of individual cases. Following our inspection, the provider shared a template to be used when supervising clinical staff.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

At this inspection we reviewed clinical records and we found appropriate arrangements were in place for monitoring medication via reviews. Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. The provider held appropriate medicines and equipment for use in an emergency; however, these were locked away and not immediately accessible to staff. Equipment for use in an emergency was stored in a number of different areas in the practice. The provider had not risk assessed the placement of these items. Following our site visit, the provider sent us a document to show all emergency equipment was stored together and was no longer locked away. There was an accompanying risk assessment for the placement of the emergency medicines and equipment.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of broad-spectrum antibiotics issued by the provider was lower than the national average. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.