Waverley PMS

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• 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 assessed a total of 4 quality statements 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.

The provider’s processes for sharing learning from significant events or incidents were unclear. Staff had not always completed the required learning applicable to their role. Staff recruitment files were not always monitored effectively to ensure they contained relevant, up to date information. Processes for oversight of infection prevention and control were not always effective. Patients did not always receive the appropriate monitoring tests for their prescribed medicines. Processes for the oversight of medicines and equipment for use in an emergency were not always effective.

This service scored 56 (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 there was no formalised process to discuss complaints and significant events, nor were these listed as standard agenda items in the minutes of practice meetings.

At this inspection in March 2025, we found complaints and significant events were listed as agenda items in clinical meetings. However, this was not the case for meetings with non-clinical staff. When asked, staff told us incidents were discussed in the practice but were unable to give a specific example of a recent significant event. Leaders at the practice shared with us an example of a recent significant event; however, we were told this had not yet been shared with staff as there had not been a staff meeting since the incident occurred. These findings meant we could not be assured that learning was identified or embedded to reduce the risk of harm to patients in the future.

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 previous inspection in July 2024, we were not assured that all staff members had completed required training or that recruitment processes were effective in ensuring patients always received safe and effective care.

At this inspection, we reviewed the training records of 2 clinical and 2 non-clinical staff members and found some records were missing. There was no record for 3 of the staff members to demonstrate sepsis awareness training had been completed. We were told the training provider for the practice offered sepsis training; however, there was no option to print certificates of completion, nor was there any way for the provider to see or evidence who had completed this training. Therefore, it was unclear whether staff had completed this training.

None of the 4 staff records we viewed contained evidence of completed training to support people with a learning disability and autistic people. The provider told us this training was not currently offered to staff.

We saw evidence that 2 staff working in the practice had completed chaperone training. We were told other staff members had completed this training; however, the provider did not hold records of completed training. The practice had 2 sites; there were insufficient numbers of trained staff to ensure a trained chaperone was available at both sites during all hours of operation. In addition, there was no signage informing patients of the chaperone service at the Welling branch surgery.

We requested evidence of staff members who had completed fire warden training. The provider told us no staff members had completed this training.

We reviewed the recruitment records of 2 clinical and 2 non-clinical staff members. The provider told us it was practice policy to carry out DBS (Disclosure and Barring Service) checks every 3 years. 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. Two clinical staff members had DBS checks in their records that were older than 3 years (one from 2015 and one from 2018).

Following our feedback to the practice, the provider sent evidence that staff had completed training in sepsis awareness, support for people with a learning disability and autistic people, and that there was a suitable number of staff trained to carry out both chaperone and fire warden duties. We were sent evidence that DBS checks had been requested for the identified staff members, initiated by the practice the day after our site visit.

There was a risk the provider would not identify and therefore mitigate risk to patients associated with staff not having the required training. For example, patients with symptoms associated with sepsis may not be identified and treated in a timely manner. There was a risk of harm to patients if staff did not have the appropriate checks prior to commencing work in the practice.

At our previous inspection in July 2024, we found concerns relating to Infection Prevention and Control (IPC). These concerns included the lack of a recent IPC risk assessment and staff records not including details of the immunisation status of staff members.

At this inspection in March 2025, we found similar concerns. We again did not see evidence of a recent IPC risk assessment. The provider had conducted an IPC audit in October 2024 which had identified 17 required actions. One such example was that liquid soap should be dispensed from wall-mounted dispensers. We saw throughout the practice that soap was dispensed from free-standing liquid soap bottles rather than wall mounted. We requested a copy of the provider’s action plan in response to this audit. This was shared with us following our site visit; 6 of the identified actions had been completed, the remaining 11 actions were scheduled to be completed by the end of April 2025.

We found the cleaning cupboard at the Welling branch surgery to be cluttered and in a difficult to access location up steep stairs. Mops were stored in buckets rather than hung to dry. The cleaning cupboard at the Plumstead main surgery was unlocked and in an area which could be accessible to patients. There was no evidence of communication between the cleaning team and practice staff. We found a clinical curtain in the GP room at the Welling branch surgery to be expired (expiry date: 06/07/2024).

We reviewed the recruitment files of 2 clinical and 2 non-clinical staff members. We did not see evidence of documented complete immunisation status for 3 staff members. For 1 clinical and 2 non-clinical members of staff there was no record of immunisation against measles, mumps, and rubella. In addition, there was also no record for one of the non-clinical members of staff of immunisation against diphtheria, tetanus, and polio. There was no documented risk assessment to accompany these staff records.

Following our site visit the provider responded to our findings. The provider told us they would revert to using a cleaning log to identify the areas of the practice that had been cleaned by the cleaning team. The provider sent evidence that a new privacy curtain had been installed in the identified GP room. We were told staff immunisation records would be reviewed.

Our findings meant that we were not assured the provider had oversight of IPC issues within the practice, and that all issues relating to IPC had been appropriately mitigated.

At our previous inspection in July 2024, we found patients did not always receive the necessary monitoring tests or medication reviews, nor were they always advised of associated risks of their prescribed medicines. The practice’s processes for monitoring equipment and medicines for use in an emergency did not always identify where equipment or medicines were not functioning or stocked.

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

The provider was unable to demonstrate they had taken appropriate action in response to Medicines and Healthcare products Regulatory Agency (MHRA) alerts. We reviewed one medicine primarily prescribed for an overactive bladder. There were 24 patients prescribed this medicine. The MHRA alert associated with this medicine advises regular blood pressure monitoring; however, all 5 patients reviewed were overdue blood pressure monitoring tests. There was no documented evidence to show these patients had been advised of all the risks associated with this medicine.

There were 41 patients prescribed medicines primarily used to treat anxiety and insomnia. We reviewed 5 of these patients There was a risk of addiction to these medicines; however, we found no documented evidence that 2 patients had been informed of this risk. There was no evidence of attempts to wean another 2 patients off this medicine.

We reviewed 5 medication reviews out of the 21 reviews that had been completed in the previous 3 months. We found 3 of these reviews lacked detailed information, such as monitoring arrangements or details about what had been reviewed.

Following our site visit, the provider submitted an action plan showing how they were going to address the concerns found during our inspection.

We found the provider had not identified nor risk assessed the absence of a number of recommended medicines for use in an emergency. At the Plumstead main surgery the provider did not hold; opiates; dexamethasone; diclofenac intramuscular injection; glucagon; or buccal midazolam or rectal diazepam. At the Welling branch surgery the provider did not hold Opiates; adrenaline; aspirin; diclofenac intramuscular injection; glucagon; or buccal midazolam or rectal diazepam. There were records showing emergency medicines were checked every 3 months; however, these checks had not identified the missing medicines.

The provider had not identified nor risk assessed the absence of some equipment for use in an emergency. At the Plumstead main surgery, the provider did not hold spare adult defibrillator pads or an adult spacer. At the Welling branch surgery, the provider did not hold paediatric defibrillator pads. The adult defibrillator pads had expired in October 2020.

At the time of our site visit, we were not assured the provider was sufficiently equipped to deal with medical emergencies. Following our site visit, the provider sent us evidence that most of the identified missing and expired medicines and equipment and been ordered by the practice. We were told the absence of opiates had been risk assessed and would not be kept on-site. We were told diclofenac was only available as a suppository and not as an intramuscular injection.