All inspections: The Queen Elizabeth Hospital

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at The Queen Elizabeth Hospital.

We inspected the maternity service at The Queen Elizabeth Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

The Queen Elizabeth Hospital provides maternity services to the population of west Norfolk, north Cambridgeshire and south Lincolnshire.

Maternity services include a maternal and fetal medicine, outpatient department, maternity assessment unit, combined antenatal and postnatal ward (Brancaster), central delivery suite / labour ward, midwifery led birthing centre (Waterlily), and two maternity theatres. Between April 2022 and January 2023, there were 1598 babies born at The Queen Elizabeth Hospital.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

Our rating of this hospital stayed the same. We rated it as Requires Improvement because:

Our rating of Good for maternity services did not change ratings for the hospital overall. We rated safe as Requires Improvement and well-led as Good.

How we carried out the inspection

We provided the service with 2 working days’ notice of our inspection.

We visited maternity assessment unit, maternity triage, delivery suite, the antenatal and postnatal ward and the antenatal clinic. We spoke with 22 people including the interim head of midwifery, an obstetrician, 3 doctors, an anaesthetic consultant, 13 midwives and two women and their families. We attended handover meetings and reviewed records.

We received 90 responses to our give feedback on care posters which were in place during the inspection.

Feedback received indicated 55% of women and birthing people had mostly positive views about their experience, although 45% had mixed or negative views. Feedback included concerns about communication, staffing numbers and support needed following birth.

Following our onsite inspection, we spoke with senior leaders within the service. We also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

The Queen Elizabeth Hospital King’s Lynn is an established 533 bed (consultant led, including adult and children and all level one care. Excluding critical care level 2 and 3 beds) general hospital on the outskirts of King’s Lynn, Norfolk. It provides healthcare services to West and North Norfolk in addition to parts of Breckland, Cambridgeshire and South Lincolnshire. The trust achieved Foundation Trust status in 2011 and is part of the Norfolk and Waveney Integrated Care System (ICS). The trust is commissioned by clinical commissioning groups from three counties. The lead commissioner is Norfolk and Waveney Clinical Commissioning Group. The local population of this area is approximately 331,000 people which includes a high proportion of older residents; however, new housing developments in recent years have seen large population growth of principally young families. The trust provides a comprehensive range of specialist, acute, obstetrics and community-based services. The trust works with neighbouring hospitals for the provision of tertiary services and is part of regional partnership and network models of care, such as the trauma network. Some specialist services and clinics were provided in community facilities, such as the North Cambridgeshire hospital in Wisbech.

Trust activity:

Between July 2020 and June 2021 there were:

55,472 inpatient admissions
245,616 outpatient appointments
68,181 A&E attendances
1,238 deaths

Our rating of services stayed the same. We rated the trust as inadequate at our previous inspection, in July 2019. We rate at core service level only when completing focused inspections. Therefore, any changes in core service ratings are not represented by the trust wide ratings table.

Our rating of services stayed the same. We rated it them as inadequate because:

Compliance with mandatory and safeguarding training was not in line with trust targets across most areas and clinical staff groups. This includes life support training for nursing and medical staff working within the emergency department.
Anaesthetists compliance with PROMPT (Practical Obstetric Multi-Professional Training) was significantly below the trust target.
Within the emergency department, facilities did not always promote peoples safety.
Resuscitation equipment was not always checked in line with trust guidance (on Stanhoe ward). Staff did not routinely remove aprons and gloves when leaving a clinical area within diagnostic imaging.
Despite active recruitment, there remained pockets where nursing, medical and allied health professional staffing numbers were below the recommended establishment. This also applied to end of life care, where palliative care consultant numbers remained lower than guidance.
Staff did not always keep detailed records of patients’ care and treatment when completing records for end of life care patients. This included the completion of mental capacity assessments.
Although staff were aware of the requirement to report clinical incidents and knew what constituted a clinical incident, staff did not report all incidents that might impact the service or patient safety.
Performance with regards to referral to treat times were not always in line with national targets.
People could not always access the service when they needed it and received the right care promptly.
Leaders in the service had a vision for what it wanted to achieve but this was not formalised in a vision and strategy.
There was increased staff engagement processes in place to communicate with staff. However, leaders acknowledged that there was further work required to engage effectively with all staff groups.
Although effective governance processes and risk management systems were in place these were not fully embedded within diagnostic imaging. Across other services, not all staff groups were regularly represented at meetings.
There were pockets within some services where the culture required further investment.
Audit programmes were not always clear which meant that oversight of performance and monitoring was not always clear.
Leaders had the skills and abilities to run the service, although had not been in place long enough to demonstrate a sustained improvement in performance.

However:

Clinical environment was well maintained and suitable to the needs of services. • Staff had access to equipment at the time of need and there were robust processes in place to ensure that equipment was safe to use and serviced regularly. • Infection control and prevention was well managed. Staff ensured that patients and their visitors were safe from communicable infections. Hand hygiene was encouraged, and staff managed clinical waste well.
Patients risks were assessed and monitored regularly. When necessary, patients were escalated, and action taken swiftly to prevent deterioration.
Staffing was maintained with the use of agency and locum staff. All areas actively recruited staff and where possible developed their own staff to ensure that there were sufficient numbers to meet demands.
Patients records detailed care and plans of treatment. With the exception of medicine services, records were held securely, accessible and shared when patients moved between departments or services.
Medicines were prescribed, administered and stored in line with guidance.
Safety incidents were recorded and investigated. Learning was shared across departments and the trust. Staff were aware of duty of candour and knew when to apply it.
We saw patients treated with respect and dignity. Staff were compassionate and included patients and their relatives in decision making.
Where possible, services were developed with patients in mind. Departments were accessible.
Local leadership teams were passionate about their services. They were visible and respected.
Services had or were in the process of developing services strategies that aligned to the trust strategy and vision. All services had plans in place of how they were going to develop.
Staff were largely positive about their roles and the services in which they worked. They spoke positively about their peers and the support they received.
Staff felt able to escalate concerns.

Our rating of services stayed the same. We rated it them as inadequate because:

Staff did not always identify, monitor and respond appropriately to changing risks to people who used services, including deteriorating health and behaviour that challenges.
The numbers and skill mix of nursing staff were not always suitable for the needs of the patients and medical staffing establishment levels were not in line with national guidance.
The number of staff completing mandatory training fell far short of the trust’s targets for all subjects and staff groups. Not all staff understood how to protect patients from abuse.
Risk assessments for patients were not always completed or updated appropriately and action was not always taken to remove or minimise risks. Not all staff identified and acted quickly upon patients at risk of deterioration.
Staff did not always ensure that information relating to a patients’ care and treatment was appropriately recorded. Records systems did not support staff to deliver safe care and treatment.
Not all services 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.
Staff did not protect patients’ dignity when providing care or protect their privacy when discussing them. Staff did not always treat patients with compassion and kindness or take account of their individual needs.
The design, maintenance and use of facilities and premises did not always keep patients safe, particularly those with mental health concerns.
The arrangements for investigating incidents and for implementing changes to practice as a result of learning from serious incidents and deaths was not robust. Investigations lacked appropriate detail, themes were not always identified, and learnings were not effectively shared. Follow up to ensure changes had been implemented was poor. Duty of candour was not being consistently carried out when required.
Monitoring results to improve safety and assess the effectiveness of care and treatment was inconsistent, when in place this was not robust. The accuracy and validity of data being utilised to monitor care was questionable.
Care and treatment was not always based on current national guidance and best practice. Managers did not always check to ensure staff followed guidance.
Staff did not always protect the rights of patients’ subject to the Mental Health Act 1983. Staff did not always understand the relevant consent and decision making requirements of the Mental Capacity Act 2005. We were not assured that staff knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
Audit activity to support and monitor the implementation of national guidance was limited. When local audit was used, this was not utilised fully, and action places were not monitored or reviewed effectively to ensure improvement in services. Performance in national audits was mixed, with limited evidence of learning and action taken to improve performance.
Patient’s needs, such as specific nutrition and hydration and pain levels, were not being identified and monitored appropriately in all areas across the hospital. Patients at the end of life were not always identified. Systems and processes were not always in place to meet patient’s individual needs.
Staff competency was not monitored effectively in all areas to ensure staff had the right skills and abilities to provide appropriate care. Appraisals were inconsistent and supervision meetings to provide support and development were not always in place.
People could not access care and treatment in a timely way. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards.
The service did not investigate concerns and complaints thoroughly to enable lessons to be learned and shared with all staff. The service did not include patients in the investigation of their complaint.
Not all leaders had the integrity, skills and abilities to run services. Not all recognised, understood or managed the priorities and issues that their service faced. Staff were not always supported to develop their skills and take on more senior roles.
Not all services had a vision for what they wanted to achieve and a strategy to turn this into action. In those that did, leaders and staff did not always fully understand or know how to apply them and monitor progress.
Positive multidisciplinary working was not in place across all areas in the hospital. Services and divisions were working in silos. Culture and morale remained poor with limited evidence of shared learning and benchmarking to improve services. Where staff felt able to raise concerns they felt that these were not always listened to or addressed.
Governance processes and systems to manage risk, issues and performance were not effective. Staff, at all levels, were not always clear about their roles and accountabilities. systems to manage performance effectively. Risks were not always identified and escalated to reduce their impact. Plans to cope with unexpected events were not always in place. Staff did not always contribute to decision-making to improvements in quality of care.
Leaders and staff did not always actively and openly engage with patients, staff, equality groups, the public and local organisations to plan and manage services. There was limited collaboration with partner organisations to help improve services for patients.

However:

There were systems and processes in place to monitor standards of cleanliness and hygiene. In the main infection control and prevention was handled well.
There were systems and processes in place for medicine management to prescribe, administer, record and store medicines.

The appointments of a new chairman and chief executive was seen as a positive. There were actions being taken to increase the level of engagement of staff across the hospital and staff recognition schemes had been reintroduced.

There were pockets of cohesive team working with learning, continuous improvement and innovation in some areas and departments.

The Queen Elizabeth Hospital Kings Lynn maternity service is operated by The Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust . The hospital has 25 maternity beds within the antenatal/postnatal Castleacre ward, there is also a central delivery suite with eight birthing rooms and Waterlily birth centre which is a midwife led centre for low risk women and has three birthing rooms. The bereavement suite for the service is located in one room on the Waterlily birth centre.

The trust provides maternity services to the populations of West Norfolk, East Cambridgeshire and South Lincolnshire. Services are provided in the maternity unit and at clinics at a neighbouring hospital at Wisbech. Community midwifery teams provide care to low risk women choosing a home birth and outreach clinics are held across the three counties.

The maternity service includes an antenatal day assessment unit at the Queen Elizabeth Hospital and antenatal clinics at both the Queen Elizabeth Hospital and the neighbouring hospital at Wisbech; Waterlily Birth Centre, the delivery suite and a combined antenatal and post-natal ward at the Queen Elizabeth Hospital site.

The last inspection of maternity services took place on the 1 and 2 of May 2018. During the inspection we found several areas of concern including lack of leadership, dysfunctional culture and concerns around the safe care and treatment of high risk women and vulnerable women.

Following the inspection CQC undertook enforcement action and served a warning notice on 17 May 2018 under section 29A of the Health and Social Care Act 2009 in respect of Regulation 12 and Regulation 17.

We carried out an unannounced inspection at The Queen Elizabeth Hospital Kings Lynn on 4 December 2018. We carried out an unannounced inspection at North Cambridgeshire Hospital on 5 December to follow up specifically on compliance with the 10 points of concern within the Section 29A warning notice.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate. As this was a focussed follow up there are no ratings attached to this inspection.

We found the following areas of improvement:

The premises at North Cambridgeshire Hospital had been risk assessed and improvements had been made to mitigate the risk to service users and staff.
Care planning for high risk and vulnerable women had improved. There were consultant leads in place and response times to see high risk women and consultant attendance at antenatal clinics were clinics were monitored.
The management of incidents had improved. Staff recognised incidents and reported them appropriately. Managers and clinicians investigated incidents and shared lessons learned with the whole team and the wider service.
The service took account of women’s individual needs. Changes had been made to ensure women who miscarried before 16 weeks were cared for in a dedicated side room on the surgical ward. Alternative waiting areas were available for women on the Brancaster antenatal and gynaecology clinic outpatient unit should they require it.
An electronic antenatal booking system was in place for women accessing maternity services. This had improved the process for the management of antenatal referrals.
Leaders had been appointed to the service with the right skills and abilities to lead the service and deliver high quality care.
The culture in the service had improved. There was evidence of improved communication, engagement and multidisciplinary team working between midwives and obstetricians.
There were improved governance processes in place to identify and manage risk. Some consultants were involved in the governance process. Risks were identified and monitored on the risk register.

However, we also found the following issues that the service provider needs to improve:

The number of consultant vacancies meant that high risk and vulnerable women did not see the same consultant at each appointment to provide continuity of care.
Although the leadership of the service had improved key leaders were interim appointments and we were concerned about the sustainability of improvements when they left the service.

Staff felt that there was not effective, timely communication keeping them updated with plans and changes within the service.

Staff reported that some consultants were still not on board with the cultural change and still displayed inappropriate and unprofessional behaviour.

The service’s audit programme was not fully embedded.

There were 32 out of 64 guidelines still outstanding that required review and update.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with one requirement notice. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals.

Staff in the cardiorespiratory department and the ultrasound department did not routinely offer chaperones or observe consultants during intimate patient imaging procedures.
Consulting staff in the breast unit did not secure patient identifiable information on computer screens when they left the room. This was a breach of the Health and Social Care Act 2008 regulated activities regulations 2014 regulation 17: Governance.
Radiology staff did not meet the trust wide target of 95% compliance for adults and children safeguarding training. Radiology medical staff achieved 64% and allied health professional staff achieved 66%.
Breast care staff achieved 75% compliance for children safeguarding training, this did not meet the trust wide target of 95%.
Radiology medical staff did not meet the trust wide target for mandatory training compliance (95%) in nine out of ten modules Including resuscitation training where only 50% of staff had completed the training.
Allied health professional staff did not meet the trust wide target for mandatory training compliance (95%) in six out of ten modules including resuscitation training where only 67% of staff had received the training.
Allied health professional staff did not meet the trust wide target for appraisal (90%) with only 61% of staff receiving an appraisal.
Staff In the computerised tomography (CT) department referred to out of date protocols and protocols which applied to a decommissioned piece of equipment.

Staff members in the radiology department did not consistently complete cleaning records. This meant that cleaning procedures were not followed appropriately and there was a potential infection prevention control risk.

Waiting times from referral to treatment were worse than the England average and the trust was reporting 47% of images within 24 hours. This was not meeting the reporting turnaround time target of 90% of images within 24 hours.

We had some concerns around the secure storage, prescription and administration of medicines. In the breast care unit staff stored personal medicines in the secure medicines cupboard. Staff in the magnetic resonance imaging unit (MRI) administered saline without the presence of a patient group directive (PGD) for its administration.

There was no evidence of sharing the learning from complaints with staff.

We were not assured the service had robust structures, processes and systems in place to support the delivery of high quality person centred care especially in the radiology department.

However,

The service managed patient safety incidents well. There had been no reported never events in the service between April 2017 and March 2018.
Staff could access appropriate records of patients’ care at the point of providing care and treatment. Staff provided care based on national guidance and monitored the effectiveness through audit.
Staff of different specialisms worked together as a team to benefit patients and always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment.
Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005 and involved patients and those close to them in decisions about their care and treatment where appropriate.
Staff cared for patients with compassion and kindness and provided emotional support to patients when required. Staff greeted patients by their name, asked patients what they prefer to be called, enquired after their comfort and protected their dignity.
The service took account of patients’ individual needs and staff knew how to access a wide range of services to improve patient experience. For example, interpreters for those patients whose first language was not English, hearing loops, bariatric equipment, play specialists and dementia champions to meet the needs of patients.
The service had a vision for what it wanted to achieve and workable strategy to turn it into action along with effective systems for identifying risks, planning to eliminate them or reduce them. Local leaders were visible, approachable and supportive to staff.
The radiology department had a comprehensive audit programme to improve performance and safety and managers across the trust promoted a positive culture that supported and valued staff.

The Care Quality Commission (CQC) carried out a scheduled focused inspection at The Queen Elizabeth Hospital Kings Lynn between the 9 and 11 June 2015. The trust had been placed into special measures in October 2013 due to serious failings and had undergone a full comprehensive inspection in July 2014 where we rated the trust as requires improvement. We carried out the focused inspection in 2015 to review services that had been previously rated as requires improvement or inadequate and to consider the current status of the trust in relation to special measures. Critical care services had been previously rated as good throughout and therefore were not re-inspected.

The trust had two outstanding warning notices in relation to safeguarding (safe and ethical restraint) and medicines management which were reviewed as part of this inspection. We judged that the trust was now meeting the requirements under the regulations and therefore we have removed the warning notices.

Our key findings were as follows:

In all areas staff were kind, caring and compassionate towards patients.
Overall the trust leadership is strong and cohesive with a clear vision and strategy, the exceptions to this being some local leadership issues within maternity and end of life services.
There is good direction and leadership from the chief executive which resonates down through the leadership team.
There is good communication throughout the organisation and the morale and culture of the organisation has improved since our comprehensive inspection in 2014.
Increased stability of the board has improved the pace of change at the trust and the confidence in the ability to drive improvements throughout the trust.
Significant improvements had been made throughout many specialties including the emergency department, medicine and surgery.
Evidence was not consistently recorded in the emergency department due to the combined use of paper and electronic systems.
Patient assessments and records were not consistent or updated to reflect changes in a patient’s condition within medicine
The total number of cancelled operations remained high however a downward trend was beginning to emerge in the number of cancelled operations alongside an improving performance on patients rebooked within 28 days.
The previous concerns regarding privacy and dignity for patients within the breast unit remained in place however the service was due to relocate to new premises which would eradicate the issues.
Patient outcomes were not being reviewed due to a lack of clinical outcome information within the maternity service.
Nurse staffing was insufficient in both the neonatal and paediatric unit.
Complaints and significant events were not being appropriately coded for end of life care so information was not being used to improve services
The hospital used a prescription and medication administration record chart for patients which facilitated the safe administration of medicines. Medicines interventions by a pharmacist were recorded on the prescription charts to help guide staff in the safe administration of medicines.
Management of medicines had improved across the trust with the exception of some storage concerns within outpatients and storage of intravenous fluids within the emergency department

In summary urgent and emergency care, medical care and surgery which had previously been rated as requires improvement have now been rated as good, alongside critical care and children and young people’s services which had been rated as Good in 2014. Maternity and gynaecology services, end of life care services and outpatients services still require improvement.

We saw several areas of outstanding practice including:

The waiting area for children within the emergency department, whilst small, was designed in an outstanding way which responsive to all children who visit the service.
The commitment of midwifery staff to develop effective midwifery services for women from the King’s Lynn area. Midwifery staff rotated throughout the service to maintain their knowledge and skills.
Relatives and staff told us the paediatric team were a well organised and effective team who provided a good service for the children and families of the Kings Lynn area.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

Ensure that medicines are stored securely at all times including those within the outpatients department, and IV fluids in the emergency department.
Ensure that resuscitation trolleys are checked in accordance with the trust policy and resuscitation council guidelines.
Ensure that an accurate record of each patients care is recorded.
Ensure that the staffing is in line with national guidance. Examples include but are not exclusive to: registered children’s nurses in the emergency department, patients requiring non-invasive ventilation, paediatric staff on the children’s ward, endoscopy medical staffing, midwives in maternity and staffing on the neonatal intensive care unit.
Ensure that there is a robust governance system to assess monitor and improve the quality of services especially in respect of decontamination of flexible cystoscopies, clinical outcome data within maternity services and the management of ASIs (Appointment Slot Issues) within outpatients.

In addition the trust should:

Review the clinical pathways especially for fractured neck of femur between the ED and the orthopaedic service and within the maternity and gynaecology services as highlighted in this report.
Ensure a system of clinical leadership developed for all areas of the maternity service with clarity about the role, responsibilities and reporting relationships. A strategic vision should be developed.
Should ensure that infection control practices are adhered to at all times in the emergency department.
The hospital should develop a joint clinical and managerial response to the review carried out by the royal college of obstetricians which provides a clear strategic vision for the service
Ensure staff training for patients living with dementia is effective in practice, and that staff can recognise the need and complete the patient passport where necessary.
Ensure the operational management structure is established and known to all staff within each service
Access to medical staff on call should be improved across obstetrics and gynaecology to ensure patients have timely access to medical advice
Develop the role of the PAU in response to the needs of the population
Ensure incidents and complaints relating to end of life care are easily identified and a process is in place to ensure learning is identified and used to influence the development of the service.
Ensure the cancellation rates and specialty clinic waiting times in the outpatients department are reviewed and improved.

There is no doubt that leadership of the trust is much stronger than in the past. This has helped to drive very considerable improvements in the quality and safety of patient care in a relatively short period of time. Importantly more of the core services are now rated as ‘good’ than when we inspected in 2014. I am therefore recommending that the trust should now come out of special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

The Care Quality Commission (CQC) carried out a comprehensive inspection between the 1 and 3 July 2014. We carried out this comprehensive inspection because the Queen Elizabeth Hospital King's Lynn NHS Foundation Trust had been identified as potentially high risk on the Care Quality Commission’s (CQC) Intelligent Monitoring system. The trust was inspected by CQC in August 2013, and was subsequently placed into ‘special measures’ in October 2013, due to the serious failings identified. We also received some whistleblowing accounts that gave us concerns.

The trust had four outstanding warning notices and eight compliance actions, which were reviewed as part of this inspection. We noted that improvements had been made around consent to care and treatment, care and welfare of patients, nutrition and hydration, incident reporting, respecting and involving service users, complaints, records and co-operating with other providers. However, the service remained non-compliant with the regulations on staffing, support for workers, safeguarding, and medicines management. The risk around medicines management has increased since our last inspection, and was having a moderate impact on the service and patients.

The trust remains non-compliant with the warning notice issued on safeguarding. This is because the trust has failed to improve the training and procedures for undertaking safe and ethical restraint of patients, and, therefore, patients and staff remained at significant risk.

The comprehensive inspections result in a trust being assigned a rating of ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’. Each section of the service receives an individual rating, which, in turn, informs an overall trust rating. The inspection found that overall, the trust has a rating of 'requires improvement'.

Our key findings were as follows:

In all areas, we found that staff were kind, caring and compassionate towards patients.
Good progress had been made in strengthening the executive capacity of the board and establishing a pace of change towards improving quality.
Evident support for the interim CEO’s style and influence across the trust, engendering a commitment to change and improvement.
Staff were proud to work in the trust.
Patients received adequate nutrition and hydration; however, medical wards, including Pentney, Necton and Oxborough, were reminded of their responsibility around nutrition and hydration needs during the inspection.
There was a ‘disconnect’ between the local leadership and the trust board leadership styles, particularly in A&E and in surgery. This meant that communication messages across all areas were mixed and not consistent.
While risks were robustly identified and placed on the risk register, there was little evidence of any action taken following this identification and recording.
Resuscitation support, equipment, training and compliance with Resuscitation Council guidance were not consistent in practice or implementation throughout the trust.
Management of medicines, including storage and recording of temperatures, was not always in accordance with national guidelines.
Medical staffing levels across the medicine directorate were not sufficient.
Skill mix across nursing staff required review to ensure that the skill mix was appropriate and to ensure the safety of patients.
Nurse staffing was insufficient in both the neonatal and the paediatric unit.
Environmentally, there were concerns with the outpatients department, which required refurbishment improvement.
The mortuary environment required refurbishment.
The A&E environment for paediatric care was not in line with national requirements.
The elective surgery cancellation rates were significantly higher than expected, and, therefore, the service was not able to meet the needs of the local people.
Infection control standards and practices around cleaning and equipment were not consistent.

We saw several areas of outstanding practice, including:

The use and implementation of guideline-specific simplified care bundles through the acute medical unit (AMU) into the hospital, which have improved patient care and patient outcomes.
The use of ‘Project Search’, which supports people in the community with a learning disability, to gain work experience and employment, in the community, and within the hospital.
The endoscopy service, operating a single sex patient list for elective cases.
The expert support available to babies transferred home with breathing or feeding requirements.
The initiative of the director of nursing to bring together all nursing leaders across the locality to review issues affecting the quality of services to patients transferring to the independent sector.
Daily surgical consultant ward rounds.
The establishment of dementia coaches to supplement the dementia team in supporting patients and families

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

Ensure that resuscitation support, equipment and training is consistent throughout the trust, and compliance with Resuscitation Council guidance is achieved. We found several examples of different equipment on resuscitation trolleys, lack of training and audit, especially in A&E and outpatients.
Ensure that the management of medicines, including storage and recording of temperatures, is done in accordance with national guidelines. We found unlocked medicines storage in outpatients and A&E and medical fridge temperatures not being recorded in medicine and surgery.
Ensure that patients are protected from the risks associated with the unsafe use and management of medicines, by means of ensuring that appropriate arrangements for the recording and use of medicines are in place. Documentation of the administration of medicines was poor in medicine.
Review and improve medical staffing levels across the medicine directorate to ensure the safety of patients through education and training.
Embed skill mix assessments for nursing staff to ensure that skill mix is appropriate and ensures the safety of patients across the hospital, but especially in A&E.
Review nursing staffing levels in both the neonatal and the paediatric unit to ensure that they meet patient acuity and dependency.
Improve the environment in the emergency department, including paediatric A&E, outpatients and the mortuary, to ensure the safety and treatment of patients.
Improve access to training; both mandatory and 'required to undertake the role' to ensure that staff have the knowledge to care for patients, for example those at the end of their life.
Review the elective surgery cancellation rates and review the elective surgery service demand.
Review medical leadership for elective and emergency surgery to ensure common patient centred aims and objectives are evident.
Review and improve cancellation rates within outpatients.
Ensure that patients are protected from infections by appropriate infection prevention and control practices, especially within the outpatients department.
Ensure that there are sufficient numbers of staff on duty, who are trained to restrain patients.
Ensure that patients are discharged in a timely manner across all wards and, in particular, at the end of their life.
Ensure that an executive director is appointed to champion the end of life services as directed by Norman Lamb MP in his letter to NHS chief executives.

In addition, the trust should:

Ensure that all staff work together effectively to enhance the experience of the patients, ensuring effective communication at all levels.
Ensure that equipment storage, within A&E resuscitation areas, is improved.
Ensure that the environment and storage of equipment in the neonatal unit is better organised.
Review the equipment used to transport the deceased from the wards to the mortuary, to ensure that it respects people’s privacy and dignity.
Ensure that there are sufficient numbers of staff who are CBRN trained. (CBRN refers to chemical, biological, radiological and nuclear equipment and policies.)
Ensure that plans to strategically move over to the national early warning score (NEWS) system are agreed and implemented. (The NEWS system relates to the management of deteriorating patients.)
Review the availability of hydration on Pentney, Oxborough and Necton Wards.
Ensure that patients are discharged in a timely manner.

We would normally take enforcement action in these instances; however, as the trust is already in special measures we have informed the regulator Monitor of these breaches, who will make sure they are appropriately addressed and that progress is monitored through the special measures action plan.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We visited the hospital at the same time as NHS England (East and Midlands) who were carrying out a rapid responsive review (RRR) of the hospital. This was because we had an agreement between the two organisations, which meant we could share information and evidence that we gathered.

Our last visit to the trust in May 2013 resulted in us asking them to take actions in order to be compliant with nine regulations. The report of our previous visit has been published and an action plan has been received detailing how the trust intends to become compliant with the regulations. Our recent visit took place in response to some new information of concern that we had received about the hospital.

During the inspection we visited in-patient wards, the maternity unit, the children's ward, the accident and emergency department and the children's out-patient clinic. We received a total of 32 comment cards about the service completed by patients or carers. 13 of these contained negative feedback and 19 contained positive feedback.

Patients told us they were satisfied with the choices of food they received and drinks were readily available. Dietary needs were catered for, for example low fat and high calorie diets. We also found sandwiches, fruit and yogurts were available at night on request from the main kitchen. The trust was able to provide food for patients with religious and cultural needs such as kosher and halal meals. We found nutritional assessments and fluid balance charts had not always been completed and the trend over the past six months had not improved.

Most patients we spoke with told us they felt safe, although two patients were concerned about the lack of staff to support patients with dementia, which made them feel vulnerable and unsafe.

Staff were knowledgeable about the issues and referral systems for safeguarding adults and children and knew the members of staff to contact if they required guidance. Norfolk County Council safeguarding team told us they felt confident in the trust's systems.

However, lack of comprehensive training for staff in dementia and low staffing levels on many general wards meant patients were at risk of receiving inappropriate or unsafe care.

We saw a shortage of nursing staff especially during our unannounced visit during the evening. Although the trust had put actions in place to increase the recruitment of qualified nurses this was insufficient to ensure that enough staff were available to meet patients' needs and care for them safely. We told the trust about our concerns immediately and they told us they would take action.

Staff felt supported by their line managers but the opportunity to attend training for nursing staff was limited because of the shortage of staff. This meant staff did not have the correct skills to deliver responsive and effective care to patients especially to those with a dementia.

The systems and processes for managing the risks to protect patients and staff were not robust. We identified that not all serious incidents were managed in the correct way and that some incidents which had been classified as serious had subsequently been downgraded. This meant that opportunities to learn lessons and improve services had been missed.

During our visit we spoke with over 60 patients who told us they had received the care they had needed. One patient said, 'The staff are kindness itself and most of them really want to do the right thing.' However, many of them told us the wards were short staffed and care was often delayed. Although some actions had been taken by the trust to address the issue they had not had sufficient impact.

We found that care was not always effective. This was because the trust did not adequately promote the welfare of patients who lacked capacity and it waS not clear how 'best interest' decisions were being made about their care and treatment. In addition, the trust did not have effective systems in place to monitor and improve the quality of the service for patients. For example, in the management of medicines and the complaints process.

We found examples where some parts of the service had not been well led. For example the trust did not always work effectively with other providers to manage the flow of patients into and out of the hospital. This often resulted in a poor experience for the patient. Care records that we reviewed were not always complete, accurate or accessible. This meant that patients may not receive safe, quality treatment and care.

Following our visit the trust informed us they had spent considerable time managing emergency pressures on a day to day basis although they accepted this had not been sufficient.

When we visited the trust in March 2012 and August 2012, we found that the trust was not meeting some of the essential standards.The trust wrote and told us about the action they planned to take. We completed this visit to check that action had been taken.

People who were receiving care told us that they were treated with respect and were kept informed about their care and treatment. We found that the wards were busy and saw that staff spoke with people in a polite and respectful manner, offered them choice when appropriate to do so and supported them to be independent.

We visited three wards and found the people that we spoke with were very complimentary about the quality of the food they received. One person told us,'The food here is good but I do not eat all of the things on the menu, such as pizza.' Most people told us they had a choice of meals they could order.

We found that members of staff provided appropriate levels of support to people who needed help to eat and drink Most of the records showed that nutritional risks were assessed and care plans to support people's needs were in place. However we found that a nutritional assessment for one person was not completed accurately and a care plan to address the person's nutrition needs was not up to date.

We found the trust had made some improvements to the quality of the care records. Regular checks were in place to monitor this improvement and actions was taken when standards fell below expectations.

People told us what it was like to be a patient in The Queen Elizabeth Hospital. They described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people in hospitals were treated with dignity and respect and whether their nutritional needs were met.

The inspection team was led by a Care Quality Commission (CQC) inspector joined by a practising professional and an Expert by Experience, who has personal experience of using or caring for someone who uses this type of service.

We visited the medical admissions unit (MAU) and an acute medical ward. We spoke with 12 people who used the service and one relative. Overall people were very complimentary about the care and treatment they had experienced. One person said,'I've no complaints about the care,' and another described staff as, "wonderful."

Most people seemed to have a good understanding of their condition and told us about their treatment in a way that suggested there had been good consultation with medical staff and some involvement with their treatment choices.

Two people we spoke with did not feel that their dignity had been respected. This was because one person had not been offered the opportunity to take a bath and the other felt staff had not respected their ability to walk to the bathroom.

In general people told us the food was sufficient and they could obtain additional food and drink on request if necessary. However we found the level of support to people at mealtimes varied and was not always person centred to meet their individual needs.

One person told us they thought there could be more staff as the call bells sometimes rang for a long time. We did not witness this during our visit to the two wards as call bells were answered within five minutes.

We looked at people's records in relation to their nutritional needs and found they did not always include accurate information about their needs. However we also saw some good records of detailed medical discussions with relatives and observed that staff were careful to ensure that personal information was not easily visible to people passing by.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

During our visit we spoke with patients on a number of wards and also with some visitors. Patients told us they were treated with respect and dignity at all times. They spoke positively about staff and described them as 'pleasant' and 'good'. Two relatives told us they had no concerns about the way staff treated patients.

Visitors were also complimentary about the staff and told us that they were well informed about the progress of patients they visited. One visitor said, 'I can't fault the care'. They told us that the patient was due to go home the following day and that appropriate arrangements had been made, following discussion with the patient's family.

Patients told us that staff explained their care, treatment and progress in a way they could understand. They said that they were happy with the care they received and that, on the whole, they were having their needs met. However, a few patients said that some staff were not very helpful and they didn't feel able to ask them for help when they needed it because staff were so busy.

Patients also told us that they were given a choice of food and that they received appropriate support to eat and drink. They said that staff knew which people required help with their meals. One patient said, 'They always reposition tables and cut up food for patients.'

All of the patients we spoke with were very complimentary about how their medicines were managed. They told us that they received their medicines on time, and were not kept waiting for pain relieving medicines or waiting for medicines at night. They told us that staff had explained to them the purpose of any new medicines they had been prescribed.

During our visit on 18 August 2011 we visited four clinical areas and spoke with a number of people and their visitors.

Most people told us that when they were admitted to hospital they were involved in the decisions made in respect of their treatment and care. One person said that staff had told them what was happening, had discussed their medication and were making arrangements for this to be dispensed, with a letter to the person's doctor, so they could go home. Conversely another person said that staff 'Didn't tell me anything.' They said they felt as if they were kept in the dark and, 'That's the way it is really.'

On the maternity ward people were very complimentary about the care and information they had received. They made comments like "Fantastic, couldn't fault them."

People told us that they had found the staff to be discreet when talking to them and asking intimate questions, always pulling the curtains around when being examined. They told us that as far as possible privacy and dignity were respected, for example if feeding the baby the staff asked whether they wanted the curtains drawn.

On the older persons' wards people who could express their views were very positive about how they were cared for. One person who was receiving care on the medical admissions unit was very complimentary about their experience. They said they felt well informed and had already been given the results of tests carried out that morning. One person was waiting to go home and said that they knew what was going to happen following their discharge from hospital. They said 'My tablets have been sorted out, the staff are very good indeed.'

People with whom we spoke mostly told us that they were very happy with the way in which they had been treated and cared for during their stay in hospital. One person said staff were very good and they had no complaints. Another said the staff were 'kind and caring.'A visitor also told us that they thought the care and treatment had been 'alright'. They said their relative appeared to be well cared for and that 'staff do a good job'. However, another visitor told us that the standard of care had not been good. They said staff did not know how to meet the needs of their relative and they had made a complaint about their concerns.

One person said that staff had been very efficient in supporting them. They said that a pharmacist had made sure that their medicines were explained to them and discussed with the consultant so they were clear about the arrangements for these before they left the hospital. However another person did not feel their ongoing care needs had been discussed.

People who were receiving maternity services told us that they had received good quality care and felt their needs were being met. One person told us that the staff were careful about infections, they were very clean, always wiping round and checking under beds.

One visitor with whom we spoke was critical of the care their relative had received in the medical assessment unit. They told us that staff had been abrupt and unfriendly ('No smile, no touching') and had declined help to take their relative to the toilet when asked, responding 'well he pulled his catheter out.' Conversely this person was very happy with the care they had received on the older person ward and said that staff were helpful and could communicate well with the people on the ward.

A number of people we spoke with gave us a good account of the choices offered at meal times. We were told the meals were good and that the choices were made on a menu tick chart the day before. They told us the food was hot and the options were healthy. One person with whom we spoke was able to give us a good example of how the hospital had improved over the past few years as they had been admitted several times. We were told that the choice and quality of food was better. Another person told us that when they were admitted they were not asked about their dietary needs. This person said they were a diabetic and able to manage their diet themselves. One visitor told us that they visited every day to ensure that their relative had a meal at lunch time. They did not feel confident that their relative would have a meal otherwise. They told us that on occasions they had visited to find that food and drink had been left out of reach. They also told us that they had observed several people on the wards who needed support with their meals and did not get it.

The Queen Elizabeth Hospital

All Inspections

24 October 2023

During an inspection looking at part of the service

7,8 December 2021 and 11, 12 January 2022

During a routine inspection

14 September to 23 September 2020

During a routine inspection

05 March to 11 April 2019

During a routine inspection

4 December 2018

During an inspection looking at part of the service

4 April 2018

During a routine inspection

9 June 2015

During an inspection of this service

9 -11 June 2015

During an inspection looking at part of the service

Professor Sir Mike Richards

1-3 July 2014

During a routine inspection

Professor Sir Mike Richards

12, 13, 14, 16 August 2013

During an inspection in response to concerns

14, 15, 22 May 2013

During an inspection in response to concerns

11 March 2013

During an inspection looking at part of the service

14 August 2012

During a themed inspection looking at Dignity and Nutrition

22 March 2012

During a themed inspection looking at Termination of Pregnancy Services

26 January 2012

During an inspection looking at part of the service

18 August 2011

During a routine inspection