Waverley PMS

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

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 the provider’s governance processes were not always effective in the identification and management of risks.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

At our previous inspection in July 2024, we found the provider had not identified that improvements were required in relation to the governance, oversight and management of risks relating to a number of areas. Staff told us they were not always given protected time to complete required training applicable to their role.

At this inspection in March 2025, staff told us they were now given protected time to complete required training applicable to their role. However, when we viewed staff training records, we found governance processes were ineffective in identifying gaps in training.

We found improvements were required in relation to the governance, oversight and management of risks relating to: monitoring of patients with long-term conditions; management of medicines requiring monitoring; safety alerts; medicine reviews; clinical audits; staff training; staff recruitment records; infection prevention and control; and monitoring of medicines and equipment for use in an emergency.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.