Date of Assessment: 9 December 2025 to 10 December 2025 Doncaster Urgent Care Centre is an urgent treatment centre provided by FCMS NW Limited under a contract held with NHS England. It is co-located with the urgent and emergency care department at Doncaster Royal Infirmary which is provided by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust. Most patients access the out-of-hours service by calling NHS 111. Patients who contact the service may be provided with advice, receive a telephone consultation, an appointment or a home visit, depending on their needs. Other patients may access the service by walking into the Urgent and Emergency Care (UEC) department (we will refer to this as ‘The Front Door’ for the purposes of this report) at Doncaster Royal Infirmary and being redirected to the urgent treatment centre waiting area, after completing a digital triage tool in UEC’s reception. The provider is registered with the Care Quality Commission to provide the regulated activities of Treatment of Disease, Disorder and Injury; and Transport services, triage and medical advice provided remotely. The service is open 24 hours per day, 7 days a week (including bank holidays) The co-located UEC department, delivered by a separate provider, was assessed simultaneously by a separate CQC inspection team. The findings of their assessment are detailed in that separate location report. Where relevant, further commentary is provided in the quality statements section of this report.
SAFE: The service lacked a good learning culture and people did not always feel able to raise concerns. Managers investigated incidents but did not use this to inform wider learning and drive improvements. People were not always protected and kept safe. Staff understood and managed risks, but they did not always feel that escalation of those risks resulted in positive changes. The facilities and equipment did not meet the needs of people, the environment was not always clean and well-maintained, and risks were not mitigated. There were not enough staff with the right skills, qualifications and experience. Managers made sure staff received training and appraisals, but not all clinicians benefitted from the same standard or regularity of competency checks. Medicines were not well managed.
EFFECTIVE: Assessments took account of people’s communication, personal and health needs. Care was typically based on latest evidence and good practice, but not consistently. During our assessment, we identified serious concerns regarding the operation and oversight of the provider’s streaming and initial triage process, which had not been identified as a risk. An ineffective streaming and triage process poses a significant risk to service users as they may not receive the care and treatment they require, in a timeframe that is appropriate for their condition.
CARING: Staff protected the privacy and dignity of patients where possible. The service aspired to support staff wellbeing, but staff did not always feel listened to. The physical environment was hot and there was a significant lack of privacy, especially at busy times.
RESPONSIVE: The service did not always provide information in a way that people could understand. People knew how to give feedback about their care and treatment. There were delays in care and treatment and the provider was trying to address this through a newly implemented streaming protocol. Some staff we spoke to did not feel equipped to deliver this without supporting governance.
WELL-LED: Leaders had a vision and culture to nurture an environment of inspiration, innovation and disruption so that the people within our world receive exceptional care for this generation and the next. Leaders were not always visible, or knowledgeable in clinical matters. Locally, managers were supportive, helping staff develop in their roles. Staff reported that they did not always feel supported to give feedback without fear of bullying or harassment. Staff understood their roles and responsibilities. There was an aspiration of continuous improvement, but staff were not given time and resources to try new ideas.
We found breaches of regulation in relation to Regulation 12 Safe Care and Treatment and Regulation 17 Good Governance. We have asked the provider to take prompt action to address the concerns identified during this assessment.