The Care Quality Commission
  • Doctor
  • GP practice

Dudley Urgent Care Centre

Overall: Good read more about inspection ratings

Pensnett Road, Dudley, West Midlands, DY1 2HQ (01384) 456111

Provided and run by:
Malling Health (UK) Limited

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Dudley Urgent Care Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Dudley Urgent Care Centre, you can give feedback on this service.

26 May 2022

During an inspection looking at part of the service

This service is rated as Good overall. (Previous inspection March 2019 – Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced focused inspection at Dudley Urgent Care Centre on 26 May 2022 following a review of information we held about the provider which triggered the inspection. We did not include the key lines of enquiry related to caring and responsive services, as there were no risks identified with these key questions.

At this inspection we found:

  • Safeguarding processes were in place. Staff had access to policies and referral information.
  • Infection control processes were in place and the premises were visibly clean.
  • The service had systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.
  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines. However, the service was not meeting the targets specified by its commissioners.
  • Staff involved and treated people with compassion, kindness, dignity and respect.
  • The organisation had procedures in place for staffing, however we found instances where rotas were unfilled, and this had the ability to impact on timely assessment and treatment.
  • Patients were not always able to access care and treatment from the service within an appropriate timescale for their needs and there were processes in place to mitigate risk, however recruitment of clinical staff was an ongoing challenge with 27% of shifts unfulfilled during the last 13 months.
  • Governance processes needed embedding further as we found fridge temperatures were not being routinely monitored and escalated.
  • Leaders understood the challenges and were working to make improvements in the service, however some systems and processes had recently been established and needed to be embedded further. For example, shift lead role, huddle meetings and escalation processes to manage patient flow and demand.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Continue to monitor that governance and clinical escalation processes are effective and make further improvements as needed.
  • Continue to monitor recruitment and make further improvements in staffing where needed.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

24 September 2020

During an inspection looking at part of the service

This service is rated as Good overall. (Previous inspection 20 and 21 March 2019 – Good Overall but Requires Improvement for Safe)

The key questions are rated as:

Are services safe? – Good

We previously carried out an announced comprehensive inspection at Dudley Urgent Care Centre on 20 and 21 March 2019. The overall rating for the service was good. The service was rated as requires improvement for providing safe services. The full comprehensive report on 20 and 21 March 2019 can be found by selecting the ‘all reports’ link for Dudley Urgent Care on our website at www.cqc.org.uk.

We are mindful of the impact of Covid-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the Covid-19 pandemic when considering what type of inspection was necessary and proportionate, this was therefore a desk-based review.

On 24 September 2020 we carried out a desk-based review to confirm that the provider had carried out its plan to meet the legal requirement in relation to the breach of regulation we identified at our previous inspection on 20 and 21 March 2020. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

We found that improvements had been made and the provider was no longer in breach of the regulation and we have amended the rating accordingly. The provider is now rated as Good for the provision of safe services. We previously rated the provider as Good for providing effective, caring, responsive and well-led services.

During this desk-based review we looked at a range of documents submitted by the provider to demonstrate how they had met the requirement notice. The documents we looked at included those relating to:

  • A revised streaming model.
  • Assessment performance data.
  • A revised mandatory training programme.
  • A revised programme of audits.

During this desk-based review we looked at the following question:

Are services safe?

We found that this service was providing a safe service in accordance with the relevant regulations.

  • Systems and processes were in place to keep people safe. The provider had introduced an assessment model to streamline patients in line with nationally recognised standards.
  • The provider had undertaken additional recruitment to support the streaming service.
  • The provider had reviewed the layout of the waiting area to provide segregation for children.
  • The provider had strengthened its training and induction programme for all staff.
  • The provider had a programme of clinical audit in place to monitor and improve quality.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

20 March 2019 and 21 March 2019

During a routine inspection

This service is rated as Good overall. (Previous inspection October 2017 – Good)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Dudley Urgent Care Centre on 20 and 21 March 2019.This was in response to concerns raised by the hospital inspection team during an inspection in February 2019.

At this inspection we found:

  • The service had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.
  • The service routinely reviewed the effectiveness and appropriateness of the care it provided.
  • Staff involved and treated people with compassion, kindness, dignity and respect.
  • Patients were able to access care and treatment from the service within an appropriate timescale for their needs.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The area where the provider must make improvements as they are in breach of a regulation is:

  • Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

  • Further improve the layout of the waiting area to provide segregation for children.
  • Complete the planned programme of mandatory training for all staff.
  • Review the programme for auditing to introduce benchmarking for those staff who audit clinicians.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

10 October 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice


We previously carried out an announced comprehensive inspection of Dudley Urgent Care Centre on 28 June 2016. The overall rating for the practice was good with requires improvement for providing a safe service. The full comprehensive report on the 28 June 2016 inspection can be found by selecting the ‘all reports’ link for Dudley Urgent Care Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 10 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the areas identified at our previous inspection on 28 June 2016. This report covers our findings in relation to those requirements.

Our key findings were as follows:

  • A system had been implemented to ensure that learning from significant events was communicated to all staff as well as to external stakeholders and healthcare professionals.
  • The reporting process for significant events had been improved to make it more readily available to all staff.
  • The lead nurse was the appointed lead for infection prevention and control. External auditors were used to monitor standards and best practice.
  • A formalised process had been implemented to ensure that controlled medicines required for a palliative care patient during the out of hour’s period were easily accessible to staff.


Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

28 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dudley Urgent care centre on 28 June 2016. Overall the service is rated as good.

Our key findings across all the areas we inspected were as follows:

  • The service had clearly defined and embedded systems, processes and services in place to keep people safe and safeguarded from abuse. There were effective arrangements in place to the support processes for identifying, recording and managing risks.
  • Although evidence demonstrated that the service effectively managed incidents and significant incidents, we found that regular meetings with front line staff such as receptionists and clinicians were not in place. Although staff felt valued and supported we found that they were often reliant on the lead GP and lead nurse to when dealing with incidents. This highlighted that staff were not always following a formal reporting process to identify and manage incidents and general concerns and that learning from significant incidents and incidents was not shared widely enough to prevent incidents from recurring.
  • We observed the premises to be visibly clean and tidy. We found that the service was in the process of appointing a named infection control lead for staff to report infection control concerns to and seek best practice advice and guidance from.
  • Some medicines management protocols were in place which covered prescribing responsibility between secondary and primary care. However, the service did not have a licence to stock controlled drugs and we found that there was not a formal process in place for obtaining controlled drugs within the out of hours service for example, to support end of life care patients.
  • The service complied with the National Quality Requirements. A programme of continuous case audits and prescribing reviews was in place, findings were used to monitor quality and to make improvements.
  • We saw that staff treated patients with kindness and respect, and maintained confidentiality. Completed comments cards and patients we spoke with during our inspection described the service as excellent and efficient.
  • We saw clear signposting in place to direct people on where to find the urgent care centre and how to access the out-of-hours service. The urgent care centre was easily accessible to patients with mobility difficulties, including wheel chair access. There were hearing loop, translation services and baby changing facilities available.
  • The process for managing complaints reflected recognised guidance and contractual obligations. Records demonstrated that complaints were satisfactorily handled and responses demonstrated openness and transparency.

The areas where the provider should make improvements are:

  • Ensure that learning from significant incidents and general incidents are shared widely enough to prevent incidents from recurring.
  • Ensure formal reporting processes are fully embedded in the service so that staff feel confident to formally report concerns when things go wrong.
  • Ensure a lead is in place to manage infection control concerns and promote best practice infection control standards.
  • Ensure key processes are formalised and easily accessible to staff in the event that controlled drugs are required for a palliative care patient during the out of hours period.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice