The Queen Elizabeth Hospital

Updated 8 July 2026

The Queen Elizabeth Hospital Kings Lynn provides a range of NHS hospital services.

Date of assessment: On the 17 and 18 March 2026 we carried out an assessment of surgery.

The rating of surgery has been combined with the ratings of the other services from the last inspections. See our previous reports to get a full picture of all the other services at The Queen Elizabeth Hospital Kings Lynn.

The rating of The Queen Elizabeth Hospital Kings Lynn remains requires improvement.

Updated 9 January 2026

On the 17 and 18 March 2026 we carried out an assessment of surgical care. This was a responsive assessment due to an emerging safety risk for people receiving care at the Queen Elizabeth Hospital King’s Lynn. We inspected all quality statements under the safe, effective, caring, responsive and well-led key questions.

During our inspection we spoke to staff, patients and families using the service. We observed how patients were being cared for and reviewed treatment records of patients.

The service demonstrated some positive practices, including good adherence to safety procedures within the operating theatre teams. However, there were concerns incidents were not always reported and staff did not consistently complete patient risk assessments. Environmental and equipment risks, such as obstructed fire exits and incorrect oxygen storage, contributed to concerns.

Staff delivered treatment in line with legislation, evidence-based standards, and patients’ individual needs. However, effectiveness was hampered by shortcomings in assessments and documentation. Compliance to World Health Organisation (WHO) standards was observed in theatres.

Staff mostly showed kindness, compassion, and respect. Patients generally felt informed and supported. Staff provided emotional support, used private spaces for sensitive conversations, and made effective adjustments for people with learning disabilities and additional needs. Frontline teams aimed to respond promptly to immediate needs. High acuity pressures sometimes caused delays.

The service engaged with partners, implemented improvement initiatives and utilised an accreditation framework to drive improvement.

During our assessment, we found concerns which resulted in a breach of regulation. The service breached legal regulations relating to safe care and treatment, and to premises and equipment. Patients’ care and treatment was not always delivered in a way that met their needs because of incomplete assessments. Access to ward areas was unrestricted.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

Updated 23 February 2022

Updated 24 July 2019

Our rating of this service stayed the same. We rated it as good because:

• The service provided mandatory training in key skills. Nursing staff mandatory training compliance was 90% on Rudham ward and 91% on NICU. Staff had safeguarding training and they knew how to recognise, and report abuse to protect patients.
• The service had suitable premises and equipment, looked after them and controlled infection risk well.
• Staff kept detailed records of patients’ care and treatment, completed and updated risk assessments for each patient and followed best practice when prescribing, giving, recording and storing medicines. Care and treatment was based on national guidance.
• The service had enough nursing and medical staff with the right qualifications, skills, training and experience to keep people safe from harm and to provide the right care and treatment. Managers made sure staff were competent for their roles, appraised staff’s work and performance. Staff of different specialities worked together as a team to benefit patients.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
• Staff gave patients enough food and drink to meet their needs and improve their health. They assessed and monitored patients regularly to see if they were in pain and promoted good health.
• Staff understood how and when to assess whether a patient had the capacity to make decisions about their care and understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff cared for patients with compassion, provided emotional support and involved patients and those close to them in decisions about their care.
• The trust planned and provided services in a way that met the needs of local people and took account of patients’ individual needs. Waiting times from referral to treatment were in line with good practice.
• Managers at all levels in the service had the right skills and abilities to run a service providing care and they promoted a positive culture that supported and valued staff.
• The service had effective systems for identifying risks, collected, analysed, managed and used information well to support its activities and engaged with patients and staff to plan and manage appropriate services. The service treated concerns and complaints seriously.

However:

• Mandatory training compliance for medical staff did not meet trust target (90%) for any of the eight modules.
• Safeguarding children level three training compliance for nursing and medical staff did not meet trust target of 95%. Nursing was 89% and medical staff was 85%.
• The service did not have enough consultants to meet royal college of paediatric and child health (RCPCH) guidance and consultant handwriting was not always legible in all medical records.
• Not all nursing staff in NICU handed over care of the babies when leaving the nursery for an extended period of time and one member of nursing staff was heard to use discriminatory language when speaking about a patient with known mental health issues.
• Staff on Rudham ward did not have a portable telephone call so that they could make confidential calls in a private area away from the nurse’s station.
• Governance structures were not embedded, not robust and did not give enough consideration to children and young people’s services and did not monitor the progress of the CYP strategy which staff were unaware of.
• There was no representation of CYP services at the quality and safety committee meetings, mortality review meetings or the mental health governance committee meetings and the service did not have a CYP specific learning disability nurse.

Updated 23 February 2022

Updated 16 December 2020

Our rating of this service improved. We rated it as requires improvement because:

• Staff mandatory and safeguarding training compliance did not meet the trust target. The service did not have enough substantive staff with the right qualifications and skills to cover all shifts. We were not assured that the out of hours staffing arrangement was sustainable and robust to provide safe care and treatment to patients. Staff did not routinely remove aprons and gloves when leaving a clinical area. Staff did not report all incidents that might impact the service or patient safety.
• Although effective governance processes and risk management systems were in place these were not fully embedded. Leaders acknowledged that there was further work required to engage effectively with all staff groups. Leaders in the service had a vision for what it wanted to achieve but this was not formalised in a vision and strategy.

However:

• Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients and acted on them. They managed medicines well. The service managed safety incidents well and learned lessons from them.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Most staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients to plan and manage services and all staff were committed to improving services continually.

Updated 24 July 2019

We rated the service as requires improvement because:

• Staff did not always complete mandatory training in line with the trust’s target. The trust target was not met for any of the seven mandatory training modules for qualified nursing and midwifery staff in gynaecology. The module manual handling had the lowest compliance rate of 33% below the trust target of 95%.
• Medical staff had not completed any mandatory training modules in line with the trust’s target. The trust target was not met for any of the eight mandatory training modules for medical staff in gynaecology. The module adult basic life support had the lowest completion rate of 52% which did not meet the trust target of 95%.
• The service utilised a high number of locum medical staff and we were not assured that all staff had the appropriate training. The trust was unable to confirm that all medical staff had the relevant ultrasound scanning competency.
• Not all nurses had the appropriate competencies in place to provide the right care and treatment. Nurses did not hold a recognised post qualification gynaecological course. Whilst competencies were in place the assessor had not completed their own competencies. However, there was access to clinical nurse specialists and midwives for advice and support.
• The service did not routinely audit the effectiveness of care and treatment and use the findings to improve them. The service did not participate in Royal College of Gynaecology Safer Standards national audits.
• People could not always access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with good practice.
• The timeliness of complaint responses did not meet local policy targets. Although the service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
• Leaders of the service did not always act on concerns raised in a timely manner. Staff did not feel empowered to improve the quality of care. Staff felt that they would escalate concerns, but no action would be taken.

However:

• There were systems and processes in place to monitor standards of cleanliness and hygiene. These included up to date policies, cleaning schedules and checklists, infection prevention and control training.
• There were systems and processes in place for medicine management concerning handling, storage and security of medicines. Staff kept medicines securely in the clinical areas we visited.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. The service took account of patients’ needs.

Updated 16 December 2020

Our rating of this service improved. We rated it as Requires Improvement because:

• Palliative care consultant staffing continued to be a concern but recognised as a nationwide problem. To mitigate any risks there was a clear demonstration of increased ownership for end of life care throughout the trust and clear recognition for the need for palliative care expertise. Consultant staffing from other local trusts were in place and we were assured they were accessible and provided support to care for patients in receipt of end of life care.
• Patient care records had gaps in the completion of Mental Capacity Act documentation. This was recognised by the trust and an ongoing piece of improvement work was being carried out.
• Patients did not always receive timely care or treatment in line with their wishes.

However:

• The trust worked collaboratively across the local health economy to introduce a new, sustainable end of life care strategy and address concerns raised at the previous inspection.
• The strategy was widely shared, and staff were engaged in the process of embedding the practical elements to ensure good quality end of life care.
• There was an executive lead, senior leadership team and clinical ownership and accountability across the trust for end of life care.
• Patient care records receiving palliative and end of life care contained Recommended Summary Plan and Emergency care Treatment (ReSPECT) documentation with do not attempt cardiopulmonary resuscitation (DNACPR) documented. Staff carried out audits to help ensure good quality completion and compliance.

Updated 1 March 2024

Updated 24 July 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

• Although the service had suitable premises and equipment in most areas and looked after them well some areas did not meet the needs of the service. For example, the diabetic clinic consulting room. This impacted on staff being able to protect patient’ privacy and dignity when delivering care.
• Outpatient areas did not routinely audit the effectiveness of care and treatment and use the findings to improve them. This had not improved since the previous inspection.
• Non-admitted referral to treatment pathway rates were below the trust’s operational standard and the England average. This meant that patients were waiting longer for appointments after being referred by their GP.
• The trust did not routinely collect data on late starting clinics or patient waits in outpatients. Main outpatients had begun to collect this data but had yet to analyse the information collected.
• Car parking facilities did not always meet demand. Patients reported that they often had difficulty parking when attending for clinic appointments which caused them to be concerned that they would miss their appointment.
• The outpatient’s department did not have a local vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
• We were not assured that local risk and performance was monitored appropriately. There was a lack of robust monitoring of referral to treatment times and control audits across all areas of outpatients.
• The trust did not have processes in place to engage with patients, the general public and local organisations to plan and manage appropriate services. Staff were positive about engagement with local mangers but reported that engagement with the trust senior executive team was inconsistent.
• There were processes and systems of accountability within clinical business units although these were not always effective. Outpatients were split over a number of different business units. There did not appear to be oversight and shared learning across all outpatient areas.

However:

• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
• The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
• The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
• The service took account of patients’ individual needs.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. The average time to investigate and close complaints was **. This had improved since the previous inspection
• The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
• Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

Updated 23 February 2022