The Queen Elizabeth Hospital

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that people and communities were always at the centre of how care was planned and delivered. We checked that the health and care needs of people and communities were understood, and they were actively involved in planning care that met these needs. We also looked for evidence that people could access care in ways that met their personal circumstances and protected equality characteristics.

At our last assessment we did not rate this key question. At this assessment the rating is good. This meant people’s needs were met through good organisation and delivery.

We have not awarded this service a score for Responsive.

Find out about when we will not publish a key question score and what we look at when we assess Responsive.

The evidence showed some shortfalls. The service did not always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

There were mixed views from patients and relatives about their experiences of receiving person centred care. We spoke with 10 patients, 6 patients spoke of being involved in and receiving good standards of care and treatment that met their needs. Whereas 4 patients or their relatives expressed concerns about not being fully involved in making shared decisions and receiving inconsistent information. These concerns were highlighted in the adult inpatient survey 2024 where the trust performed “somewhat worse than expected” or “worse than expected” in 11 questions related to patient experience and involvement in care. The trust provided an action plan to address key themes.

“This is me” patient passports were personalised documents, developed by the Alzheimer’s society, that help patients quickly share their needs, preferences and important information with healthcare staff to support person centred care. The trust encouraged their use to support patients. However, during our assessment we observed that these documents had been left blank and patients and their relatives had not been supported in completing them.

Staff mostly ensured patients were given a choice of food and drink to meet their cultural and religious needs.

The service made reasonable adjustments to allow for additional visiting for some patients, for example, those with additional support needs were accompanied by relatives and carers during treatment.

The trust had a learning disability specialist nurse who worked with individuals to create bespoke care plans. The service offered support at outpatients appointments for those patients attending without carer support.

We were told of an example from the Day Surgery Unit where a neurodivergent patient was supported with an individual nurse with them at every part of their elective surgery pathway.

The evidence showed some shortfalls. There were some shortfalls in how the service understood the diverse health and care needs of people and their local communities.

Information boards were found on the wards with key information such as dietary requirements, manual handling requirements and mobility status to ensure continuity of care. However, we observed these were not always completed to accurately reflect the patients’ needs.

Patients’ care and treatment was not always delivered in a way that met their needs because of incomplete assessments. For example, nutritional risk assessments were not completed in 6 of 10 reviewed patient records to identify potential risks and plan necessary mitigations.

Staff told us discharge planning for patients with complex, ongoing needs is coordinated by a dedicated team. This team supported the surgery wards by attending daily board rounds, provided expert advice and supported patient discharge. Referrals can be made to Norfolk First Support (NFS) where required to ensure care continuity, this included access to community-based rehabilitation. Data from the trust showed that 60% of patients referred to NFS were discharged within 24 hours.

Staff told us they referred patients to required specialist services, such as speech and language therapy and occupational therapy when required. Specialist services for diabetes management, tissue viability and stoma care were also available. Staff told us patient reviews happened in a timely manner although this was not audited.

The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service met accessibility information standards and supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs upon request.

Translation services and interpreters were available to support patients whose first language was not English. This included British Sign Language.

Patients were given information leaflets to explain surgical procedures.

Some patients and relatives told us they were not always informed about their discharge arrangements. However, leaders told us about an initiative trialled on Elm Ward to improve the provision of discharge information. Each week an MDT meeting took place and involved patients and their relatives to discuss and formulate discharge plans. This process had reduced the average length of stay for patients from 22 days to 11 days. Staff told us this had reduced the number of complaints received.

Information sharing between teams seemed to be cohesive. We were given examples of multiple ways in which staff shared information throughout the division including daily MDT face to face huddles.

The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

Patients we spoke with knew how to give feedback about their experiences of care.

The service enabled people to easily share feedback, ideas and complaints about their care. Staff involved patients in decisions and informed patients of changes made to their care as a result.

The service gathered feedback through various tools, including NHS Friends and Family forms and the hospital’s reporting system.

Between December 2025 and February 2026, the surgical division received 47 formal complaints, 36 of which were responded to in the time frame set out by the trust’s policy. Appropriate divisional staff investigated complaints and members of the executive team responded to the complainant. Key themes identified were poor communication and delays to treatment. Staff discussed complaints at monthly learning events and specialty governance meetings.

We saw evidence that the division had implemented Martha’s Rule. Martha’s Rule is a patient safety initiative that gives patients and families the right to request an urgent independent clinical review if they were worried that a patient’s condition is getting worse.

The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

Staff were able to order specialist equipment such as air mattresses and bariatric equipment as required. All staff we spoke to knew how to access equipment if needed to support care and treatment of patients.

The trust had processes in place to identify patients that may require additional support, such as individuals with dementia, autism or a learning disability. These patients were identified by medical and nursing teams who would then inform relevant parties. Staff made reasonable adjustments to support individuals such as pre-arranged visits prior to planned surgery.

The learning disability nurse supported inpatients with a learning disability. The nurse visits patients on the wards supporting with communication, enabling reasonable adjustments and supporting discharge. Access to this service was made by electronic referral.

Leaders told us Oliver McGowan training was mandatory for all staff. We were not provided compliance figures for this in the trust’s mandatory training data. As such we were not assured staff have received this training.

The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff had a good understanding of patients that used the service and were most likely to experience inequality in their care. Staff completed equality, diversity and human rights training as part of their mandatory training. Compliance for this training module met the trust target with 88.6% of nursing staff and 89.4% of medical staff within the surgical division having completed it. However, only 70% of medical staff on training had completed this training module.

Patients told us their needs and preferences were assessed and understood by staff. They told us they were treated in a non-discriminatory way.

Staff told us they treated people equally and without discrimination. They were able to give examples of how they respected the individual wishes of people with protected characteristics.

All policies we reviewed had an equality impact assessment completed ensuring they did not place vulnerable people or people with protected characteristics at a disadvantage.

Leaders told us they offered outpatient pre-assessment clinics in areas that had beds to patients that had mobility restrictions ensuring clinical assessment and MDT access was equal to those without mobility concerns.

The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

During our assessment we reviewed ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) forms and Do Not Attempt Resuscitation (DNAR) forms for 4 patients. These had a documented conversation with the patient or their representative around the individual resuscitation status and had clear clinical rationale as to why resuscitation would not be in the patient’s best interest.

Patients told us they had been given advice and information on how to manage at home after surgery.

Physiotherapists were involved from the earliest stage to proactively work with patients. This helped achieve the best outcomes. Patients’ length of stay was below the national median value.