Medway Community Healthcare C.I.C

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

Our overall rating for Safe of the urgent treatment centre stayed the same. We rated it as Requires improvement. We were concerned that the service did not ensure that the premises and equipment were managed well. The provider did not take all practical steps to remove the risk of infection. We told the provider in 2022 that it must make improvement on how it manages infection risks and the environment. We saw on this assessment that the provider had failed to make the required changes.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff and leaders reviewed incidents and learned lessons.

All staff knew what incidents to report and how to report them. Staff reported all reportable incidents in line with the providers policies and procedures including reporting to external agencies such as CQC.

The service reported 7 incidents between August and September 2025 including but not limited to information governance breach, chemical exposure, medicines related errors, and data security breaches. We saw that lessons were learned following these incidents.

The service did not have a never event in the last 12 months. Never events are serious preventable medical errors that should never occur while under the care of a medical professional because, robust systems and processes should be in place to prevent them happening.

Staff understood the duty of candour. They told us it was about being open and transparent and giving patients and their families an explanation when things went wrong. The service did not have any incidents which met the threshold for the duty of candour in the last 3 months.

Leaders investigated incidents and learned lessons. Staff received feedback from the investigation of incidents both internal and external to the service.

The service had a clear criterion for who they would offer a service. The service accepted patients for conditions such as simple infections, minor illness and ailments, urgent (non-acute) medical requirements including simple trauma related wounds, falls, frailty vulnerability, deep vein thrombosis and cellulitis. The service provided care and treatment to people within the Medway and Swale areas, as well as people outside of these localities who may or may not have a GP.

Patients who attended the urgent treatment centre, had pre-arranged appointments via the NHS 111 service. Patients were also referred (streamed) to the urgent treatment centre by the AE department at Medway Maritime Hospital. There was a clear process for patients who wrongly attended the urgent treatment centre but required support at the emergency department and access to specialty team.

The service monitored waiting times from clinical assessment to treatment. We spoke with 11 patients that were streamed through the acute trust emergency department to the urgent treatment centre. All but one patient said they were triaged quickly within 30 minutes of arrival. As of September 2025, the service was reporting the two-hour triage compliance rate of 89%.

Staff ensured essential information was shared with other services as required such as the NHS trust, the patient’s GP, social care services and other third sector agencies, to ensure patients had continuity of safe care, both within the service and post-discharge.

All staff including clinical and administrative staff had received training specific for their role on how to recognise and report abuse. The service reported in Quarter 1 (April to June 2025) that 90% of staff had completed their mandatory safeguarding training, and 96% of staff had received safeguarding supervision by their line managers.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. The service had a safeguarding flag in their electronic record system which alerted staff when an adult, a child or young person could be at risk of harm, neglect or abuse. These flags allow frontline staff to immediately identify if a child is on a protection plan or if an adult has known vulnerabilities.

Staff followed safe procedures for children visiting the service. There was a separate waiting area for children. However, at the time of the inspection the children waiting area door did not have a lock. On the last inspection, we told the provider it must take action to protect people visiting the department including children. Managers told us they were waiting for the locks to be installed.

Staff knew how to make a safeguarding referral, and who to inform if they had concerns and for advice. The service had a safeguarding lead who staff could contact for advice and support. Safeguarding was a standing agenda item on the team’s monthly Integrated Quality and Performance Assurance Committee (IQPAC) and Audit and Risk Committee meetings.

All their findings were fed back to staff in the quality and safety newsletter; cases were discussed in staff supervisions.

The service worked collaboratively with partner agencies, including local authority safeguarding teams, to support effective safeguarding arrangements. Information was shared appropriately to ensure people received coordinated protection and support.

Mental Capacity Act

Staff were trained in the Mental Capacity Act (MCA) 2005. MCA training was part of the dementia awareness training. Staff understood their roles and responsibilities under the Mental Capacity Act including the understanding and application of the five statutory principles.

Staff told us they always sought consent from patients and carers and gave them a chance to make their own decisions. Patients we spoke with told us that staff took practical steps to enable them to make their own decisions.

The service had developed a flowchart that supported clinicians to make decisions when a patient was deemed as lacking capacity to make a specific decision. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regards to significant decisions.

Staff told us they took account of people’s wishes, feeling, culture and history when they made decisions in the patient’s best interest.

Staff considered Gillick competence for children and adolescents (Gillick competence is a test in medical law to decide whether a child of 16 years or younger is competent to consent to medical examination or treatment).

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.

Staff involved people in discussions about their treatment and discussed any risks with them. Staff worked with patients in reviewing risks and developing care plans particularly for patients suffering from cellulitis and deep vein thrombosis.

Staff used a nationally recognised tool to identify deteriorating patients and escalated them appropriately. Staff assessed patients using National Early Warning Score (NEWS) 2 to determine the degree of illness of the patient which prompted critical care intervention.

Staff knew about and dealt with any specific risk issues. The service assessed people for risk of sepsis, falls and pressure ulcers.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties.

The service could refer people to other services including mental health liaison and specialist mental health support, if staff were concerned about a patient’s mental health.

Staff completed, or arranged, psychosocial assessments and risk assessments for patients thought to be at risk of self-harm or suicide.

Staff shared key information to keep patients safe when handing over their care to others. Shift changes and handovers included all necessary key information to keep patients safe.

The service carried out periodic friends and family test surveys, where people could give feedback on the service they received.

The service did not ensure that the premises and equipment were well maintained and fit for purpose. During our assessment of the urgent treatment centre, we observed that the chairs at reception were damaged and they needed repairs or replacement. The coverings were broken with the foam exposed. We also observed that the furniture in the consultation rooms was damaged, and needed to be repaired or replaced, and this was posing a risk of injury and infection to people attending the service. We raised our concerns with the provider during our assessment, and the provider informed us that there were new chairs on order, however, there were no clear dates for when replacements would be delivered.

There were signs on broken chairs notifying people not to sit on these. However, during our assessment we saw that people were sitting on the broken chairs. This was a risk because the provider should have removed the chairs if they were known to be broken and unsafe.

While the unit had a front entrance, this was locked and barricaded at the time of our assessment. Leaders told us that because they did not have control over who comes through the department. They had decided to close the front entrance as having an additional door would not be beneficial. Patients said going through the main hospital to get to the urgent treatment centre created uncertainty as to whether they were at the right place.

Following our last inspection in February 2022, we told the provider it must take reasonable and practicable steps to safeguard and protect children and young people attending the service. On this inspection we saw that while there was now a separate waiting area for children the controlled access door lock had not been installed.

The children’s waiting area was not child friendly. There were minimal toys or child-friendly equipment for the children waiting however there were decorative stickers and murals on the walls. Managers informed us that the toys had been destroyed by the children visiting. The provider had not replaced the items that were destroyed.

On the last inspection, we told the provider it must take action to ensure the urgent treatment centre was not being used as a thoroughfare by people who were not visiting the service, to access other parts of the hospital. On this assessment we saw that this has still not been addressed. Managers had raised concerns with the trust and provider that the unit was being used as a thoroughfare to get to other parts of the hospital. This could put people at risk because staff were not always aware of who was in the department and their purpose. For example, a patient from the emergency department who needed to be assessed under the Mental Health Act 1983 had barricaded themselves in the urgent treatment centre and staff were not initially aware.

Reception staff told us they monitored people who attended the service via closed circuit television (CCTV) and could see all areas of the unit.

We spoke with patients and visitors who raised concerns about the poor state of the environment. One patient said that they did not feel this was a hospital environment and that it felt like a corridor. Another patient reported that they had seen several people walking through the department who did not appear to be patients.

The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank, agency and locum staff a full induction.

The service was reporting a low vacancy rate across all staff groups. The service ensured that sickness and absences were covered by locum, bank or agency staff. Managers limited their use of bank and agency staff and requested staff familiar with the service.

The average sickness and absence rates for staff was below the providers target of 3% in July, August and September 2025 for nursing and medical staff. However, the sickness and absence rate for allied health professionals was high at 19% in July 2025.

Managers made sure all staff including bank and agency staff had a full induction and understood the service. We observed during the assessment that the medical director was providing training and induction to medical students and new staff members.

On the last inspection we told the provider that it must ensure that staff completed their mandatory training including face to face training. On this assessment we saw that staff completed most of the mandatory and statutory training modules including face to face training. However, only 58.4% of staff had completed the Oliver McGowan training on Learning Disability and Autism.

The mandatory training was comprehensive and met the needs of patients and staff.

Clinical staff completed training on recognising and responding to patients with mental health needs, learning disabilities, autism and dementia. The service also provided intermediate life support (ILS) training in recognising and responding to deteriorating patients to provide emergency resuscitation until a cardiac arrest team arrived. However, only 52% of eligible staff had completed this training at the time of the assessment.

Managers monitored mandatory training and alerted staff when they needed to update their training. The training was appropriate for the patient group using the service.

Managers supported staff to develop through yearly, constructive appraisals of their work. This was an area of improvement since the last inspection.

Managers supported all clinicians including doctors and nurses to develop through regular, constructive clinical supervision of their work.

Managers made sure staff attended team meetings or had access to full notes when they could not attend.

Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge.

Staff had the opportunity to discuss training needs with their line manager and were supported to develop their skills and knowledge.

Managers made sure staff received any specialist training for their role.

Managers identified poor staff performance promptly and supported staff to improve.

The provider did not take all reasonable and practicable steps to control the risks and spread of infections. The environment, including the toilets, were not cleaned regularly and high standards of cleanliness were not maintained throughout the day. We observed empty food wrappings on the floor in reception area. Staff told us that the cleaners employed by the acute trust did the cleaning. The service operated a 24-hour service, but the domestic and cleaning staff cleaned the unit once a day.

Toilets and general areas did not always have signs to use the hand sanitizers. We observed that the soap dispensers had come off the wall in one of the toilets and left on the sink. There were damp patches and mould in the toilets.

There were no notes or stickers to indicate when an area or equipment had been cleaned; for example, with the use of “I am clean stickers”. At the time of the inspection the provider could not show us cleaning records. The service did not maintain a cleaning schedule.

Staff did not ensure that sharps bins were assembled correctly, and we found one sharp bin left open. In one of the consultation rooms, a pack of urinary dip sticks was left open on the handwashing sink. This item is moisture sensitive. Exposure to humidity or water causes the chemical reagents on the testing pads to degrade prematurely, leading to false-positive or false-negative results.

The visitors’ toilets were old, broken and dirty and one of them did not flush properly. One carer reported they were worried about their child using the toilet, because they did not want to leave with a hospital acquired infection.

The provider had reported rodent infestation on site. Staff were told not to leave the windows open, to prevent the mice and squirrels from coming into the building. Staff reported that due to the environment and rodent infestation, there had been an increase in the number of seagulls in the area. While we did not see clear signs of mice droppings on the unit, we were concerned that the poor culture of cleaning and maintenance could put people at risk particularly young children.

The providers cleaning and infection control audit indicated that the service had repeatedly failed its audit for quarter 1 (April to June) and quarter 2 (July to September).

Poor and infrequent cleaning exposes patients, staff, and visitors to Infection control risks. Patients with reduced immunity could be at risk of hospital acquired infections which could pose significant risk to health.

We shared our concerns with the ICB following assessment. The service was working with the acute trust with support from the to address the concerns we found around infection risks.

Staff reviewed each patient’s medicines and provided advice to patients and carers about their medicines to ensure they remained appropriate and effective.

Staff reviewed the effects of medicines on people’s physical and mental health and acted where concerns were identified, supporting ongoing safe use of medicines. People were referred to their GPs for monitoring and follow up.

The service ensured that medicines and treatments were managed safely and effectively. Staff followed systems and processes to prescribe and administer medicines safely. Staff followed national practice to check patients received the correct medicines.

Medicines records were completed accurately and kept up to date. Staff stored and managed all medicines and prescribing documents safely.

Medicines were in date, clinic room and fridge temperatures were checked regularly. Where there were concerns following the checks, these were escalated appropriately.

The service had a pharmacist that undertook periodic review of medicines and its use. The service conducted regular medicines audit and acted when issues were identified. Staff learned from safety alerts and medicines related incidents to improve practice.

While there was a clear inventory of medicines, staff did not always ensure that the dispensary was always kept clean and tidy. We observed that the medicines room was cluttered with different medicines on cabinet top and in baskets.