Eastham Walk In Centre

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• 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.

This was the first comprehensive assessment for this service as a location registered with CQC. This key question has been rated as requires improvement. We have identified breaches of regulation for safe care and treatment relating to incident management, staff training and staffing.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We were not assured that the service had a proactive and positive culture of safety. The trust used the ‘Patient Safety Incident Response Framework’ (PSIRF) for managing safety incidents and events and a Clinical Risk Management Group (CRMG) maintained oversight of safety events and reported through to a ‘Safe Operations Group’. Staff were aware of how to report incidents and near misses and there was evidence of incident reporting at location service level. We saw some examples whereby incident themes or trends had recently been analysed and were being acted upon. These related to staffing and wound management. We found a number of examples where it had been identified that there had been no learning from events when the nature of the event would suggest otherwise. We looked at the management of a significant event and we found some level of investigation and analysis. However, the information supplied did not clearly demonstrate that a thorough and detailed investigation had taken place. The outcome and actions omitted significant potential learning points and action had not been taken in a timely way. There had been missed opportunities for learning and a delay in sharing learning from the event to prevent a recurrence. The rational for deciding the impact of the incident was not in line with the outcome for the patient and the incident had not been reported through the NHS system for the reporting and analysis of patient safety events that occur in healthcare. The learning had not been shared effectively across the team and timely and comprehensive action had not been taken to improve procedures and prevent a recurrence. The governance of the management of safety events had not identified these gaps in the investigation and learning and had failed to ensure timely, effective and comprehensive action had been taken.

The provider worked with healthcare partners to establish and maintain safe systems of care. There were systems and processes to share information with staff and other agencies to enable them to deliver safe care and treatment. The service sent communication to the patient’s GP to inform them of the care and treatment provided. The service used a different patient record system to that of the majority of the GP services in the locality. This could present a risk to delivering the most effective care and treatment for patients presenting with more complex needs. The provider told us they were reviewing the use of the current IT systems to improve this.

Staff told us they used established care and treatment pathways to support the patient journey. However, we received feedback from staff that they would like to see more clearly documented pathways and standard operating procedures to support them in their role and improve the patient journey. We asked the provider to share a number of standard operating procedures with us. Some of those requested were not available or has only recently been produced.

Members of the staff team were aware of local services and support networks that they could refer people to in order to support them with their needs and to prevent ill health.

The service worked to safeguard people from the risk of abuse and there were systems and processes to respond when it was suspected that people may be subject to abuse or neglect. The service worked with partner agencies to share information to safeguard people. Policies and procedures were reviewed and up to date and were aligned with other local safeguarding teams.

The provider had a designated safeguarding lead. Staff had been provided with safeguarding training at a level that was appropriate to their roles and responsibilities. Not all staff were up to date at the time of the assessment. This was in part due to long-term sickness.

Staff had guidance for managing safeguarding, including outside of standard business hours. Staff had a clear understanding of safeguarding and they knew the action to take if they had concerns about a patient’s safety and they told us they would feel confident to report concerns. We heard of an example where a safeguarding concern had been alerted resulting in action being taken and a significant positive impact for the person concerned.

The provider told us they were completing a gap analysis to establish if there were any risks around sharing of safeguarding alerts across different healthcare providers and patient record systems.

Staff told us they informed the health visiting service if they referred a child to the Emergency department (ED or AE). We noted there was no protocol for staff to check if the child had attended or had been accompanied to attend.

The provider carried out staff recruitment procedures in line with requirements to ensure staff were appropriate to work in the service.

People who used the service underwent an initial assessment (triage) to establish their level of risk and prioritise them for care and treatment, in accordance with their clinical need, before a more comprehensive assessment was carried out. Staff told us they understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. However, we noted there had been a period of months between March to June 2025 where paediatric immediate life support training compliance was between 58% - 65%. This had improved in recent months to an attainment of 86% of the team.

Staff had been provided with training and support on how to identify and manage patients with a range of presenting illnesses and conditions including severe infection such as sepsis. However, this training had been delivered during staff induction and for some staff this was a number of years ago when they had commenced their employment. The provider could not demonstrate that staff were up to date with training in these areas or to ensure the training delivered was in line with the needs of people attending the service. We found that standard operating procedures for managing presenting illness or conditions were not always available to staff.

People who used the service were advised on risks related to their condition and actions to take if their condition deteriorated and how to seek further help. Staff told us that safety netting advice was provided but we were not assured that this was always clearly documented in patient records as identified in an audit of consultation records and in the learning from a patient safety event.

Risk factors, where identified, were highlighted to patients and their normal care providers so additional support could be given. Where patients’ needs could not be met by the service, staff redirected them to the appropriate service to meet their needs.

The provider identified and controlled potential risks in the environment and had a clear infrastructure to support and govern health and safety, estates and facilities. The provider made sure equipment, facilities and technology were maintained and supported the delivery of safe care. However, we had to seek assurance that all risks were being mitigated as some of the original documentation shared with us did not have up to date information about how the risks were being managed.

The facilities and equipment met the needs of people who used the service and staff and risks associated with these were mitigated. A regular programme of audit/checks was in place to ensure the safe and effective running of the service. Contracts were in place to ensure the premises were clean and well maintained.

The service was located in a purpose-built building that provided the required facilities such as safe access and facilities for people who were physically disabled.

Staff had been provided with training in health and safety related topics such as fire safety, infection control and manual handling. A review of fire safety arrangements had identified some delays in carrying out fire safety related checks and fire warden training for staff. The provider had taken action to rectify this.

The provider had a business continuity plan in place to provide guidance for dealing with a major disruption to the service, for example an IT failure.

Systems were in place to plan and monitor staffing and lead nurses were actively managing staffing across services in an aim to meet fluctuating demand and service pressures.

Staff told us that staffing levels and time pressures were a concern for both staff and patient safety and welfare. They told us staffing shortages was impacting on their ability to undertake training and to take annual leave. They told us staffing levels were impacting on staff morale, with a knock-on effect on staff sickness and turnover. Staff told us they did not have protected time for them to undertake training, learning and professional development and some felt they had not received training appropriate and relevant to their role. The provider had recently introduced 30 minutes of protected learning time per month. Staffing levels had been a concern raised by staff for some time but the provider had not addressed these concerns effectively.

The staff survey from 2024 had identified workload pressures and staffing challenges. The provider had detailed their intention to; review staffing models to ensure safe and sustainable workforce levels, focus on workflow redesign, reduce unnecessary administrative burden, and maximise clinical time. However, staff told us the staffing pressures had increased over the past 12 months.

The provider was aware of ongoing staffing concerns, which were reported through the incident management system and discussed at trust board level. The provider had identified staffing as a risk on their risk register and mitigating actions were identified to address this. However, to date the service continued to carry staff vacancies, staff sickness was high and staff concerns about staffing remained. The staffing levels had fallen below minimum levels on a number of occasions over the past six months and the provider had carried out an analysis of this linked to incident reporting. The provider shared a learning from incidents review relating to staffing for the period August 2024 – August 2025. They told us the service has listened to feedback from staff in relation to staffing levels and had implemented several change ideas to improve resilience in the staffing model, improve communication with staff, promote effective decision-making during times of high demand and recruitment to vacancies.

The concerns for safe staffing also related to the agreed staffing establishment. Whilst we were told that the staffing establishment had recently been reviewed and was appropriate to meet the needs of the service staff told us that staffing levels could present a significant challenge when patient demand and acuity was high or there were staff absences. The provider did not monitor patient acuity as a means to determine if the current staffing model continued to meet the changing needs of people who used the service and the demand. The presentation of people who used the service had changed over time with a high number of people attending for wound management and dressings. The provider told us there was a pilot commencing September 2025 with regards to the provision of a wound dressing clinic.

The service had an escalation policy in place so that staff could request additional support should demand exceed anticipated levels. This policy had only recently been introduced. On occasions when the service moved to triage only staff continued to manage and assess patients who required a fuller assessment and treatment.

The provider maintained a record of staff training compliance for core mandatory training and we saw that compliance was high for the majority but not all mandatory topics. Training in ‘Immediate life support’ (ILS) for adults and for children/paediatrics (PILS) was below target and had dipped a few months earlier. Alongside this, with the exception of topics covered in induction there was no clear minimum requirement for training for staff based on the needs of the people using the service and no associated training plan. Staff told us that they were seeing a greater number of complex patients with polypharmacy and polymorbidity and they felt the training provided did not always reflect the care and treatment needs of people attending the service.

The provider told us that nursing staff were required to undertake training in treating children. However, there was no evidence that this had been undertaken in the staff training records that were shared with us. Additional information on service specific training was provided but this related to induction and did not include all staff as per staff rota. The absence of information regarding staff training meant there was no assurance that each shift included staff trained in immediate life support or paediatric care.

Staff also told us they would like to see more pathways put in place and more standard operating procedures for managing and treating patients with specific needs. We found a delay in the introduction of a protocol and standard operation procedures as a means to improve outcomes for people who used the service where the provider had recognised a need to improve. Learning from a patient safety event had identified that there was no written guidance for managing patients presenting with chest pain. A number of protocols were introduced in response to our findings.

Staff underwent formal one to one supervision that included an overview of the assessment and consultation process and prescribing decisions made by non-medical prescribers. Staff underwent an annual appraisal and processes were in place for carrying out a review and competency check for each nurse prescriber. Staff were supported to identify their training needs as part of their appraisal but they told us there was limited protected time for them to undertake training.

Staff attended a daily meeting referred to as a staff ‘huddle’. This was a meeting where important information about the service, staffing and patient information was discussed and where issues could be escalated. At the time of the assessment this was predominantly the only form of meeting that staff were attending. A monthly meeting was in place but this had not been attended by front line staff. We found during our assessment that the ‘huddle’ was not an effective means of communication between all staff. The service implemented changes to improve this and additional processes for dissemination of information/ meetings were also introduced during the time of our assessment. These were not yet embedded so their effectiveness could not be assured.

Despite the level of concern raised by staff with regards to staffing they told us that teamwork was good and they supported each other well. Positive feedback included “The team is fantastic” and “The service provided is really good”. But they were concerned that this was at the cost of staff wellbeing and was not sustainable.

The provider carried out staff recruitment procedures in line with requirements to ensure staff were appropriate to work in the service. All new staff underwent an induction programme and were required to undertake mandatory training.

There was an effective approach to assessing and managing the risk of infection, that was in line with current relevant national guidance and standards.

The premises were purpose built, clean and contained the appropriate facilities to minimise the spread of infection. Personal protective equipment was in good supply and located appropriately around the premises.

Staff roles and responsibilities around infection prevention and control were clear with a dedicated lead person and staff had undergone training appropriate to their role.

Contracts were in place to ensure the premises were clean and well maintained. Cleaning schedules were in place and infection prevention control and cleaning audits were carried out on a regular basis. Cleaning equipment was stored securely and in line with best practice.

The systems and arrangements in place for managing medicines, including medical gases, emergency medicines and equipment, and vaccines, minimised risks.

Our findings showed that medicines were managed safely and the approach to medicines reflected current and relevant best practice and professional guidance.

Staff followed established processes to ensure that when people were prescribed medicines their GP was informed. All non-medical prescribers were required to be registered as such, complete an annual review using a standardised clinical review tool and were required to have a declaration to practice. A system was in place to review a sample of the non-medical prescribers’ consultation and prescribing decisions. Audits were carried out to support safe prescribing and ensure it was in line with best practice. These included quarterly audits (carried out by the medicines management team) to look at antimicrobial prescribing, controlled drug prescribing and all other prescribing. The audits assessed if prescribing was in line with guidance, if the patient’s allergy status was documented correctly and to check that a full drug history was documented in the patient record.

There was a system in place to ensure that Patient Group Directions (PGDS) (written instructions to supply or administer medicines to patients in planned circumstances, such as vaccinations) were read, signed, dated and maintained appropriately.

Staff had access to emergency medicines and equipment including oxygen and a defibrillator. Emergency medicines were regularly checked for stock availability and to ensure they were in date. The medicines were stored securely. However, the provider should consider a review of the current arrangements to ensure the medicines continue to be stored safely but can be readily accessed by staff at all times.

Systems were in place to manage and respond to safety alerts and medicine recalls.