This service is rated as Good overall. (Previous inspection 11 2017 – This service was rated Good overall, but was rated requires improvement for providing safe services.)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Urgent Care Centre Queen Mary Hospital on 3 November 2016. The overall rating for the service was good. However, a breach of regulation 12(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was identified, and we rated the service as requires improvement for providing safe services. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Urgent Care Centre Queen Mary Hospital on our website at www.cqc.org.uk.

We carried out a desk-based follow up inspection on 7 September 2017 to check if the service had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 3 November 2016. At our follow-up inspection we found the service had not made sufficient improvements and was still rated as requires improvement for providing safe services, but remains rated as good overall.

We carried out this announced comprehensive inspection at Urgent Care Centre Queen Mary Hospital on 13 November 2018 as part of our inspection programme and to follow up on the breach of regulations identified at our previous inspections.

At this inspection we found:

• The service had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.
• The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated people with compassion, kindness, dignity and respect.
• Patients were able to access care and treatment from the service within an appropriate timescale for their needs.
• The service had improved its performance against National Quality Requirements, and was now meeting set targets
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Review and risk assess decision not to carry a defibrillator and oxygen in the vehicle used to attend GP out of hours home visits

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Urgent Care Centre Queen Mary Hospital on 3 November 2016. The overall rating for the practice was good. However, a breach of regulation 12(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was identified, and we rated the practice as requires improvement for providing safe services. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Urgent Care Centre Queen Mary Hospital on our website at www.cqc.org.uk.

This inspection was a desk-based follow up inspection carried out on 7 September 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 3 November 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The practice is still rated as requires improvement for providing safe services, but remains rated as good overall.

Our key findings were as follows:

• The provider had updated their policies and documents in relation to dealing with significant events and ensuring business continuity to reflect the arrangements at the service

• The service had improved its performance against National Quality Requirements, butwas not yet meeting set targets

• The provider had a centralised system for risk reporting and management

• The service has a translation service for patients who need it

There were still areas of practice where the provider needs to make improvements.

The provider must:

• Continue to improve its performance against National Quality Requirements

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Urgent Care Centre Queen Mary Hospital on 3 November 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

• There was an open and transparent approach to safety and an effective system for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• The service had an effective streaming system, although outcomes of the number of patients consulted within 15 minutes of arrival were lower than targets set by the commissioners of the service.
• The systems for the out of hours service were effective and ensured that patients were followed up as required.

• Feedback from patients about access to the service and treatment received was consistent and highly positive.

• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.

• The service understood the needs of the changing local population, increased demand on local health services and had planned services to meet those needs.

• The service had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The service proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

The area where the provider must make improvements is:

• The service must ensure that the time that patients take to be triaged is in line with those set by . This relates to both the urgent care and out of hours services.

The areas where the provider should make improvement are:

• The service should review the serious untoward incidents policy and the business continuity plan to ensure consistency of policy and practice. The business continuity plan should also include all Clinical Commissioning Group contacts.

• The service should consider bringing all identified risks into registers managed by the service, rather than rely on those used by the owner of the building.

• Consider using a formal translation service for patients who need it.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice