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 a total of 2 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the January 2019 inspection, which was good. Our rating for this key question is requires improvement. We found that patients with long term conditions did not always receive appropriate monitoring. The provider was unable to demonstrate quality improvement through clinical audits. Uptake of cervical cancer screening and childhood immunisations were lower than World Health Organisation (WHO) recommendations.

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.

Our clinical searches found patients with long term conditions did not always receive appropriate monitoring, referral and follow up.

We shared our findings from the clinical searches with leaders at the practice. Staff were unaware of the concerns raised, prior to our clinical searches being carried out. Following our assessment the provider shared an action plan which detailed how they planned to address the concerns found.

We reviewed the records of 5 patients with asthma who were prescribed 2 or more courses of rescue steroids in the past 12 months. We found 3 of these patients had not been warned regarding the risks of being on high dose steroids and had not been issued with emergency cards. We reviewed the records of 5 patients with chronic kidney disease stage 4 or 5 and found that 2 patients had not received appropriate referrals or follow up. We found a number of patients with hypothyroidism had not had the required monitoring in the last 18 months. We reviewed 5 patients and found 3 patients had not had a medicine review in the past 12 months. The other 2 patients had received medicine reviews; however these reviews did not include a review of their thyroid medicine. We did not see evidence of a process to recall patients with hypothyroidism for monitoring tests. We reviewed 5 patients with diabetes and found 2 patients had not had a diabetic review in the last 12 months. Another patient had received a diabetic review but this did not include a review of their diabetic medicine. This patient had been prescribed a medicine with an associated safety alert; however the patient had not been advised of the risks associated with this medicine. We identified 3 patients with a potential missed diagnosis of diabetes. All 3 patients had blood tests which indicated diabetes; however all had been coded as suspected or pre-diabetes.

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.

Published data showed that patients didn’t always receive cervical screening or childhood immunisations in line with national targets or World Health Organisation (WHO) targets. Staff were able to share with us details of the steps taken to encourage patients to attend for screening tests or immunisations.

Staff told us they would take action to encourage patients who were hesitant about cervical screening or childhood immunisations. Staff contacted patients who had missed appointments and were given the opportunity to speak to a member of clinical staff if they had concerns regarding cervical screening or immunisations.

The provider showed us evidence that clinical audits had been completed. However, these were limited to single-cycle audits and therefore did not demonstrate quality improvement. When asked the provider confirmed these audits had not been repeated.

Published results showed the uptake rates for cervical cancer screening were below the 80% target for the national screening programme. Data from June 2023 showed uptake at 62.8%. Performance for this indicator had decreased since March 2020. The World Health Organisation (WHO) recommends an uptake rate of 95% for all routine childhood vaccinations. Published results from April 2022 to March 2023 showed: • 80% of children aged 5 had received immunisation for measles, mumps, and rubella (MMR). • 83.3% of children aged 1 had completed a primary course of immunisaiton for Diptheria, Tetanus, Polio, Pertussis, Haemophilus influenza type b (Hib), and Hepatitis B. • 88.2% of children aged 2 had received immunisation for MMR. • 82.4% of children aged 2 had received their booster immunisation for Pneumococcal infection. • 79.4% of children aged 2 had received their immunisation for Hib and Meningitis C

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.