Urgent Care Centre

On this page

• 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 looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as Good. At this assessment, the rating has changed to inadequate.

The service was in breach of legal Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to safe care and treatment.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety but did report safety events. Analysis of root causes was not driving safety improvements and lessons were not always learnt to continually identify and embed good practice.
The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Managers told us they encouraged staff to raise concerns when things went wrong. Staff told us they did so, but their concerns were not always addressed or managed. Individuals who raised incidents received a direct individual update or feedback from this. However, there was limited wider learning and dissemination that came from incidents and complaints. Some staff we spoke to did not know how to raise concerns. Learning from incidents and complaints sometimes resulted in changes that improved care for others.
 

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.
A new system of streaming had been introduced the week prior to our assessment and was live during our onsite visit. This involved patients using a digital self-check at the ‘front door’, in which identifiable information was collected using a version of NHS 111 online triage. Patients were then redirected to the urgent treatment centre if that was the appropriate outcome from the information provided to the digital platform. There were only a limited number of digital tablets in operation and patients queued up to use them. They sometimes experienced delays in being redirected to UTC and they had not had baseline observations recorded at this stage. If patients were seen in the UEC department initially, then referred to UTC, the patient potentially joined the end of the queue at the UTC. This could result in a wait of several hours. We saw that some patients could not be adequately observed in the waiting area of the UTC when it was busy. There was no monitoring of how long patients waited before having baseline observations and National Early Warning Scores (NEWS) taken. NEWS is a process of recording, scoring and responding to changes in routinely measured physiological parameters in acutely ill patients. The service aimed to do them within 30 minutes (NHS England target is 15 minutes). The streaming technology had the potential to be an improvement tool for the provider, but it was not yet fully embedded in all its phases and there was limited data collection to support where it was succeeding or failing during our assessment.
The provider had also identified a learning point around escalation out of hours, where clearer guidance and pathways may have enabled quicker clinical decision-making.
 

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately, however we saw two examples from the provider’s own commissioner reporting tools where staff had failed to identify safeguarding concerns in the previous 12 months.
Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. Managers acted on concerns, working in partnership with other organisations and actively asked for updates where they had made referrals for patients about whom they had concerns. Records that we looked at supported this.
 

The service worked with people to understand and manage risks. They provided care to meet people’s needs that was as safe as they could make it within the unpredictable peaks of workload.
Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. However, there were delays in contacting people who had been unable or unwilling to wait in the UTC department after check-in. The environment was not set up to effectively and safely observe patients for signs of deterioration. Some patients could not be viewed around corners or behind pillars. The busyness on the system meant that staff had insufficient time to immediately identify clinical risks. The service had an escalation policy, which included an OPEL (Operational Pressures Escalation Levels) reporting system. OPEL is an NHS framework used to consistently measure and manage demand and capacity across health services.
We saw several examples from clinical incidents with the previous 12 months where clinical escalation had not been effectively implemented, including a patient at the end of their life, and a patient at risk of neutropenic sepsis.
 

The service did not always detect and control potential risks in the care environment. They tried to make sure equipment, facilities and technology supported the delivery of safe care.
The computer system used in the UEC was a different system to that used in the UTC. This made the sharing of accurate and timely data and information relating to patients difficult. The provider was aware of the risks and was continuously trying to mitigate this.
Contracts were in place to ensure the premises were maintained by the acute trust who hosted the UTC premises. However, the premises were in poor condition. There were inadequate spaces to wait, to store equipment, or to deliver clinical care. The unit was hot and there was little ventilation, no external windows and poor visibility of waiting patients within the UTC. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed. Information from staff following our inspection, received directly by CQC, described faulty equipment used to measure children’s oxygen saturations. Staff told us they had escalated concerns about this on several occasions, but this was not replaced.
 

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.
There were a range of clinical and non-clinical roles within the practice. We found training was mostly up to date (around 85% compliance). Not all staff were working within their agreed areas of competence. We saw that there were some concerns routinely reported to the commissioning board around the scope of practice for healthcare assistants. Information of concern directly to CQC, corroborated this. Safe recruitment practices were followed.
We looked at staffing rotas, but it was difficult to ascertain how these rotas supported real-time acuity and pressures. We were told that during busy periods, additional clinicians were brought onto duty. Feedback from staff was negative about the sufficiency of staff for delivering safe care on daily basis. Staff told us that additional resource was arranged based on arbitrary decisions, rather than real perception of clinical prioritisation, clinical risk and clinician concern, and this made them feel unsafe. Staff told us they regularly had patients waiting significantly longer than 4 hours and there was no appropriate escalation procedure. They felt that there was no visible senior clinical or operational leadership and the lack of serious, untoward clinical incidents was due to the pro-activity of clinical staff to maintain an individual professional level of service provision.
 

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies.
The practice had a designated infection, prevention and control (IPC) lead and all staff had undertaken relevant training. Feedback from staff working at the service told us that the IPC lead was not given any protected time to enable them to carry out their lead role. Staff told us that they had frequently escalated concerns about IPC matters to managers, but nothing changed as a result. Some cleaning schedules were in place and followed but there were gaps. Risk assessments and audits were completed but there some gaps. Actions were sometimes taken to mitigate risks. On the day of our site visit we saw unlabelled urine samples that had not been discarded from the night shift. The environment was cluttered with inappropriate items in clinical areas. Staff were not ‘bare below the elbow’ in line with best practice for infection prevention and control. There was one sharps bin for the UTC, but this was housed in the clinical utility and used to prop open the door. It was not possible to safely discard sharps (blood glucose lancets) which were used in a different room into this sharps bin. We saw used and dirty coffee cups in clinical areas that had been discarded and remained unwashed. Mops and buckets were not kept hygienically and safely in a clinical utility room. We observed a member of staff who was clearly unwell and at risk of spreading and acquiring infection but leaders had not instructed them to remain at home. Privacy curtains were not dated. Staff told us curtains were not changed regularly. The medicines storage was cluttered with non-medicines-related items.
The provider told us that clinical rooms were cleaned between clinicians’ shifts but there was no schedule for this or evidence to support it was happening.
There were limited practical options to isolate patients in a timely manner, in the event of a contagious infection, due to a lack of space, lack of ventilation, and the time spent in communal areas being triaged, streamed and waiting for baseline observations.
 

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.
Medicines were not stored safely and securely. Access to medicines was not restricted to those who required it. This could lead to medicines being mishandled, used incorrectly and stored in the wrong way. There was no temperature monitoring taking place where medicines were stored. During the inspection the temperature exceeded 30 degrees Celsius, which is outside the manufacturers’ guidelines for most medicines which need to be stored at room temperature. There were no policies in place to show staff what to do if maximum temperature storage was breached.
Prescription pads were not stored securely. Rooms containing prescription pads were unlocked when not in use, increasing the risk of unauthorised access, misuse or theft.
We looked at all prescriptions issued from 01 December 2025 to 08 December 2025. Staff stated all pre-labelled medicines that are given out from the urgent care centre should be logged onto a paper record and checked by a second member of staff. This should only occur out of hours or if an immediate dose is required. Staff were not following this process which meant there was no audit trail of medicines that left the service.
We found multiple times when pre-labelled medicines were supplied from the urgent care centre during working hours. These prescriptions should have been issued to the patient and dispensed by an outpatient pharmacy. When prescriptions were issued, we found the log was not always completed and not checked by a second member of staff. Of 111 issued, only 19 were recorded on the log. The policy was not being followed; therefore, this could lead to incorrect medicines being given to patients, without thorough checks taking place to ensure the correct item had been given to them. A new project was underway to address why prescriptions were being issued during working hours and to improve prescription auditing. However, as this was in its infancy, we were unable to see improvements made at the time of the inspection.
Two operations specialists had oversight of checking weekly stock counts and expiry dates, including emergency medicines. However, we did not see evidence of security tag serial numbers being recorded to ensure the contents of the emergency bag had not been tampered with. This included medicines transported in the car used for home visits. We did not find any expired medicines during the inspection, but we did find some medical device sundries had expired in clinical rooms and in the car used for visiting patients at home. Staff told us there was no regular process for checking these expiry dates.