Waverley PMS

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We assessed 1 quality statement from this key question. We have combined the scores from these areas with scores based on the rating from the last inspection which was requires improvement. Our rating for this key question remains requires improvement as we found the service continued to deliver poor care.We found patients did not always receive the appropriate monitoring tests for their long-term conditions. The provider was unable to demonstrate quality improvement through the use of clinical audit.

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.

At our previous inspection in July 2024, we found that patients with long-term conditions did not always receive appropriate monitoring, referral, and follow-up.

At this inspection in March 2025, we conducted remote searches on the practice’s clinical system and found similar concerns to those identified at our previous inspection.

We found patients on the asthma register had not always received an asthma review.

Patients with hypothyroidism had not always had the required monitoring tests. There had been some attempt to contact patients to attend for their monitoring tests; however, there was no evidence of a process to follow up on patients who had not responded to these reminders.

We identified 2 patients with a potential missed diagnosis of diabetes. Both patients had test results that would indicate type 2 diabetes; however, both patients had been coded as suspected/pre-diabetes. This meant these patients would not receive the necessary reviews and monitoring tests at the required intervals for patients with diabetes.

At our previous inspection in July 2024, the provider was unable to demonstrate quality improvement through the use of clinical audits. At this inspection in March 2025, we requested evidence of clinical audits carried out by the provider. We were shown evidence of 2 single-cycle audits; however, the provider confirmed that these audits had not been repeated, and therefore did not demonstrate quality improvement.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Monitoring and improving outcomes during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.