Arrowe Park Urgent Treatment 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. We assessed all quality statements from this key question. At this assessment we rated the service as requires improvement and we have identified a breach relating to risks, incidents, staffing and staff training in safe care and treatment.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider established systems and processes to monitor and review safe care and treatment. Incidents were reported on the trust’s incident reporting system and learning opportunities were discussed through the governance structures. However, the evidence submitted at governance level did not demonstrate that all learning identified reached all staff at location level in a timely manner, where it could directly improve patient safety, clinical effectiveness, and staff confidence.

The organisation had high level processes to identify, understand, monitor, and address current and future risks, including risks to patient safety such as staffing levels. However, the processes did not work effectively, because although staff identified risks, the organisation did not always take appropriate action in a timely manner.

Staff at the location prioritised safety, openness, and joint working. They reported safety events through the incident management system, and these were managed at service level. However, the learning outcomes did not always show that investigations or actions taken were appropriate. Although reported incidents were audited, there was evidence that poor practice and learning was not always identified, although we saw more recent examples of where this was demonstrated.

Staff said they understood their responsibility to raise concerns and report safety incidents, near misses, and risks internally and externally when appropriate. However, we found that feedback after incident reporting was inconsistent. Some incident reports lacked detailed documentation of investigations or follow-up actions. Learning was not always achieved and embedded into good practice.

During periods of extreme demand in one site, the responsible lead person would redeploy staff to meet service need, meaning staff could be moved to another location during a shift if required. The trust was in the process of creating “one front door” for the emergency department and urgent treatment centre, which was currently in temporary accommodation. When patients required urgent or complex medical care, they could transfer to the emergency department (ED) adjacent to the UTC and vice versa for patients who did not require emergency treatment but still required immediate support.

Staff maintained individual care records in a way that promoted patient safety. Commissioners and system partners did not raise any concerns about delayed referrals or the safety of care systems. The organisation collaborated with service users and healthcare partners to establish and maintain safe care systems. We saw evidence of regular meetings with local stakeholders and partners to develop standard operating procedures across organisations.

However, within the organisation, staff told us, and we saw, a lack of documented procedures available to staff provided in a timely manner to ensure safe systems, pathways and transitions. For example, there was no standard operating procedure (SOP) for all staff around the management of chest pain. Several SOPs we would expect to see used in an urgent care setting were introduced only during the month of the assessment.

Clinicians followed established care pathways for diagnosis, treatment, and referral to specialist services. Staff used secure and timely referral systems to share information with patients’ GPs, out-of-hours services, and secondary care. An effective electronic management system was in place; however, the service used a different patient record system than most local GP practices, posing a potential risk to coordinated care for patients with complex needs. The provider reported reviewing its IT systems to address this issue, but we were not assured that summary care records were consistently available or reviewed during all consultations.

The service had appropriate systems to safeguard children and vulnerable adults from abuse. Urgent Care Safeguarding Champions were in place to support safeguarding practice within the locations. These staff had a special interest in safeguarding, and acted as a point of contact for colleagues, to provide guidance on safeguarding concerns, and help deliver safeguarding supervision. We spoke to staff who were aware of their roles and responsibilities around safeguarding, however not all knew who their safeguarding lead person was.

All staff received safeguarding and safety training appropriate to their role, but not all staff were up to date at the time of the assessment. This was in part due to long-term sickness. Staff knew how to identify and report concerns. Learning from safeguarding incidents was available to staff.

Alerts were added to the patient record system when there were safeguarding concerns about a patient so that all relevant members of the staff team could readily identify this. The trust had identified that a gap analysis was required to identify any missing data across three systems that were used within the service location.

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. There was a chaperone policy in place to maintain patient privacy during intimate examinations. Posters highlighting access to a chaperone were displayed in bays and waiting areas.

Risk registers were maintained but there was mixed evidence on whether there was effective management to reduce the risks.

Clinical staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They had been provided with training and support on how to identify and manage people with severe infections such as sepsis. However, the information provided by the trust did not demonstrate that this training was recent or up to date. Administration staff had received training and had access to information to recognise the deteriorating patient.

People were prioritised appropriately for care and treatment, in accordance with their clinical need. This included patients being triaged by a clinician using national early warning tools for children and adults to help assess the severity of acute illness and the recognition of clinical deterioration. There was a target for patients to be triaged within 15 minutes of arrival, and a SOP to inform clinical observations. However, the SOP did not advise staff to repeat clinical observations to monitor changes if the target was not met.

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. From the case notes reviewed on-site the safety netting appeared proportionate to the various contexts.

There were systems to manage patients who experienced long waits. New television screens had been installed in the waiting areas providing information such as anticipated waiting times. Patients transferring to other services, such as AE, had a formal handover to emergency department staff. Patients were provided with information on when to seek further help and advice if their condition deteriorated. Consultation notes were sent to patients’ registered GPs electronically, usually within 24 hours to ensure timely follow up was received if required.

The service detected and controlled potential risks in the environment and had a clear infrastructure to support and govern health and safety, estates and facilities. There were local service level agreements with the owners of the premises and regular meetings took place to review risks and monitor the contracts.

The provider made sure equipment, facilities and technology were maintained and supported the delivery of safe care. There were systems in place to test all equipment and ensure it was safe to use.

The service had health and safety and fire risk assessments in place. However, significant actions from the most recent fire risk assessment remained outstanding. A fire assembly point for UTC staff had not been designated, despite this being a basic and essential safety requirement. This was inappropriately rated as medium priority with a 3-month completion target. Fire marshal training, also incomplete, was rated as low priority with a 6-month target. No evidence was submitted at the time of the assessment or since the assessment to assure the CQC that these basic and essential safety requirements were in place.The lack of timely action on these matters demonstrated insufficient oversight and posed a potential risk to the safety of staff and patients.

The provider also maintained a business continuity plan to guide staff during major disruptions, such as an IT failure.

The use of security personnel protected people against disruptive or violent behaviour.

The provider monitored patient demand for the service and reviewed staff capacity to meet anticipated needs. However, there was insufficient evidence to show that enough qualified, skilled, and experienced staff were consistently in place to maintain a safe service. The provider identified low numbers of appropriately experienced staff and high sickness levels as a risk to be managed.

The organisation followed safe recruitment practices to ensure all staff, including agency staff, were suitably experienced, competent, and capable of carrying out their roles when employed. It implemented processes to confirm staff were fit to work, such as conducting Disclosure and Barring Service (DBS) checks.

All new staff completed a comprehensive induction programme and were required to undertake mandatory training within appropriate timescales. The provider used competency frameworks to support continuous learning and professional development. However, they could not demonstrate when staff had most recently received training in areas relevant to working in an urgent treatment centre.

Not all staff were up to date with Immediate Life Support (ILS) and Paediatric Immediate Life Support (PILS) training, partly due to low staffing numbers and sickness absence. The provider stated that rotas were arranged to ensure at least one ILS- and PILS-trained staff member was on duty each shift. However, despite being requested, the provider did not submit evidence to corroborate this. Between March and June 2025 training compliance in this area was as low as 58% - 65% but had improved more recently to 86%.

Although arrangements were in place to plan and monitor staffing numbers and skill mix, staff reported that minimum staffing levels were not always sufficient to meet service needs. The organisation was aware of this. Risk registers were maintained, but evidence of effective risk management remained inconsistent. Leaders reported that three new staff members had recently been appointed, while staff said they had raised staffing concerns for over two years. On the morning of the assessment, sickness absence stood at 20%. Following the visit, leaders reported that sickness levels had reduced to 11.5%. They stated that an escalation policy was in place, though staff said it had only been introduced during the assessment month and had not yet been evaluated.

We reviewed staffing rotas for the Urgent Treatment Centre (UTC) between 26 May and 23 August 2025. The data demonstrated, and the Trust confirmed, that the service operated below the optimal staffing level for 40% of those shifts. We were told that mitigations were in place for these shifts as lead nurses and GPs were available to work clinically. We saw from the data provided that this was the case for some of the days and for some of the shift period. However, this was not always the case. On several occasions, according to the rota there was no lead nurse available. The rota also showed periods when only two staff members were on duty for several hours of a shift, which staff confirmed had occurred.

The provider held meetings with non-medical prescribers to review prescribing practice and ensure appropriate management of medicines prescribed. Staff said they were supported to identify training needs and professional development goals but struggled to attend training due to low staffing levels.

The provider was aware of ongoing staffing concerns, which were reported through the incident management system and discussed at Board level as a manageable risk. In August 2025, the provider introduced an escalation policy (Standard Operating Procedure) for times when the Urgent Treatment Centre, Minor Injuries Unit, or Walk-In Centres reached full capacity and decisions to ‘triage away’ were required.

The provider had a system to manage infection prevention and control (IPC).

There were clear roles and responsibilities around IPC management with dedicated lead staff. Staff had been provided with IPC training.

IPC was a risk being carried by the trust for two years due to lack of space caused by the proximity of temporary accommodation. The most recent IPC environmental audit of the Urgent Treatment Centre was completed 13 December 2024 and produced an overall score of 90% for the setting. The risk would not reduce until the UTC was relocated to the new setting currently being built. The forecast date for the move was June 2026.

The arrangements for managing waste, sharps and clinical specimens kept people safe.Staff vaccination was maintained in line with current UK Health and Security Agency (UKHSA) guidance, if relevant to their role. There was a system for the service to report infection-related concerns to the relevant agencies (e.g. notifiable diseases).

The service managed medicines well at trust level with reliable systems and standard operating procedures in place. There was a programme of regular clinical audit of prescribing that focused on improving care and treatment. Reviews of non-medical prescribing practice were regularly undertaken. The provider had a system to record and act on safety alerts and medical recalls.

At location level vaccines were stored following guidance and fridge temperatures were recorded to maintain cold chain requirements.

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. These were monitored and audited regularly.

The service was equipped to respond to medical emergencies (including suspected sepsis). Staff had access to emergency medicines and equipment, including oxygen and a defibrillator. Most staff were suitably trained in emergency procedures, but there were gaps due to low staffing levels and long periods of sickness and we were not assured that all staff on duty at each shift were up to date with training in immediate life support for adults and children or sepsis management.

Emergency medicines were regularly checked for stock availability and to ensure they were in date, and we noted there had been incidents reported when this was not the case. Learning about this had been delivered. Emergency medicines were stored securely and managed safely. However, the trust did not provide evidence when requested, that it had risk assessed the suitability of the medicines held locally for the service. When people were prescribed medicines, their GP was informed.