The Queen Elizabeth Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.The service was in breach of legal regulations in relation to the safe care and treatment and premises and equipment.

We have not awarded this service a score for Safe.

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

The service listened to concerns about safety and investigated and reported safety events.

From December 2025 to March 2026, 332 incidents had been raised for the surgery division and 313 had been reviewed and 19 required further information prior to review at the surgery divisional incident huddle as per the trust policy. Leaders told us these huddles happened 4 times a week to ensure timely review of incidents.

Identified incident themes included the management of diabetes on surgical wards and we saw actions in place to share learning.

We reviewed the last 2 investigations related to patient safety within the surgery division and found these followed a structured approach and highlighted where lessons were learnt.

Leaders told us they take a multidisciplinary approach to reviewing incidents and develop action plans to prevent reoccurrence and share learning with staff. Staff we spoke to were able to give examples of recently reported incidents and how learning had been implemented. For example, a staff member told us of the development of the rib fracture pathway.

Staff and leaders we spoke to told us they completed daily safety huddles to raise awareness of reported incidents and immediate actions to be taken to reduce risk. Additionally debriefs were carried out following a patient fall to ensure learning is shared and actions put in place.

Some of the areas we visited had noticeboards which provided examples of how the department had learned from incidents. Displays provided guidance on ways staff could reduce the risk of incidents.

Staff we spoke to told us they would raise safety incidents and were encouraged to do so by senior leaders. However, a Royal College of Surgeon report from 2025 raised concerns about staff’s ability to discuss issues in a non-confrontational way, which impacted learning culture.

Staff we spoke to understood their responsibility for duty of candour. Duty of candour is a legal requirement for all health and social care providers to act in an open and transparent way with people receiving care. This means that when something goes wrong that causes, or could cause, significant harm, the provider must inform the person (or their family), explain what happened, offer an apology, and outline next steps. There was an up to date openness and candour policy in place. There had been 7 incidents that required duty of candour in the last 3 months, 100% of these had been completed in line with the trust policy.

The evidence showed some shortfalls. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

During our inspection we found gaps in documentation in patient records and patient risk assessments not completed appropriately. Following the inspection, we requested copies of documentation audits for the surgical wards. The results of these audits showed report scores ranging from 70.2% to 91.8%. Leaders told us improvement was needed in this area and we were shown ongoing actions to improve documentation standards.

During our onsite visit, we found 6 out of 10 patient Malnutrition Universal Screening Tool (MUST) risk assessments were not completed. MUST is widely used five step method in healthcare to identify adults at risk of malnutrition, undernutrition or obesity. Following the inspection we requested 3 months of MUST compliance audit data. Reported compliance for the four surgical wards was below 90%. Leaders informed us they had action plans in place to address this concern.

The trust had a discharge checklist to support safe and effective discharges. We did not observe this being used during our inspection. Audit data showed this checklist was not completed at the required time for any patient in the last 3 months. As such, we were not assured that care needs were effectively communicated at discharge. Leaders told us this was an ongoing issue, and a review of the document was due to take place to improve completion rates. The target for implementation of the new document was quarter 1.

The trust used National Early Warning Score 2 (NEWS2) as a standardised system to detect early signs of clinical deterioration in adult patients, and we observed this being used during our inspection. For example, a patient had a high score, indicating potential clinical deterioration, the senior nurse on the ward reviewed the patient and escalated the concern to the appropriate clinician. This was in line with the trust policy. Following the inspection we requested 3 months of NEWS2 audit data. Reported compliance for the four surgical wards was above 90%.

The trust assessed patients for the risk of venous thrombosis on admission and reassessed them at 72 hours. Appropriate interventions to reduce risk were implemented. Trust audit data for the last 18 months showed the service was meeting the trust target.

During our inspection we did observe staff assisting patients to mobilise with the use of appropriate equipment. Staff kept ward areas clutter free, therefore reducing risk of inpatient falls. We requested audit data to ensure patients had an accurate falls risk assessment completed on admission. The trust advised that significant work is ongoing to improve completion rates of these assessments.

The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

The trust provided staff with safeguarding level 3 training that was specific to their role. Nursing staff training compliance for safeguarding adults was 62% and for safeguarding children was 67%. Medical staff training compliance for safeguarding adults was 49% and for safeguarding children was 55%. The trust target was 80%. Leaders told us the reason for poor compliance was because training expectations had changed in December 2024, but we were not shown an action plan to improve compliance.

We reviewed the last 3 referrals made to the safeguarding lead and these showed staff were identifying vulnerable people and taking action to keep them safe.

There was an up to date safeguarding vulnerable adults’ policy. Staff we spoke to understood safeguarding and told us if they were concerned about someone’s welfare, they would escalate this to their manager. Staff were able to identify categories of abuse, but they were not able to share a recent example.

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

During our inspection patients told us that staff explained treatment options to them and their relatives and gave them time to ask questions before making a decision. Patients told us explanations were given to them in a way that they could understand.

Staff communicated with patients so that they could understand their care and treatment. This included finding effective ways to communicate with patients with communication difficulties. For example, staff had access to translation services for patients whose first language was not English.

During our inspection we saw documentation of conversations with patients and their relatives around resuscitation status. The trust provided audit data for the completion of Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms for the last 3 months. ReSPECT forms document conversations between individuals and healthcare professionals and record preferences for emergency care. The audit data showed good compliance in completion of these forms.

During our inspection we saw the implementation of Martha’s Rule. Martha’s Rule gives patients, families, and carers the right to urgently request an independent clinical review if they feel a patient’s condition is worsening and not being taken seriously.

The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Access to the surgical wards was not restricted and was uncontrolled. We observed a lack of professional curiosity to challenge visitors posing a risk to both staff and patient safety and welfare.

There was clear signage for emergency exits on wards identifying escape routes. However, on some wards, there were found to be obstructed by equipment. This was highlighted to staff who rectified this during the inspection.

During our inspection we observed oxygen cylinders being stored incorrectly and this posed a safety risk. This was escalated to staff during our visit. Areas where medical gases were stored were not clearly identified.

Equipment, including special or adaptive, was available and used to deliver care and treatment that was suitable for the intended purpose. Equipment was clean and ready for use and up to date electrical testing was displayed where required. We reviewed 15 items across surgical care wards and found all were labelled and tested in line with health and safety executive (HSE) guidelines.

Although doors to sluices or storage rooms were not always locked, cupboards containing hazardous substances were locked securely. This ensured hazardous substances were locked away safely from reach.

Staff disposed of clinical waste safely. Sharps bins were labelled correctly and not over-filled. Staff separated clinical waste and used the correct bins.

Emergency trolleys were easily accessible within the service. We checked the emergency trolleys on the surgical wards and found these were secured with a snap lock, so it was clear if someone had accessed the resuscitation equipment.

The operating theatre department was visibly clean, but we observed the corridors were cluttered with equipment. Staff told us the department lacked space for adequate storage in part due to the aging estate.

The evidence showed some shortfalls. They did not always make sure staff received effective support, supervision and development.

Leaders told us that staff across the surgical division were being supported to attend face to face mandatory training sessions to ensure there is rapid progression to the trust target of 80% compliance. We asked for data for core training modules and this showed inconsistent completion rates. For example, 100% of medical staff had completed level 1 resuscitation training but we were not provided with this data for nursing staff. As such we were not assured that all staff receive appropriate training.

Vacancy rates within medical staffing for the division was 8.2% and when combined with staff sickness rates this equates to 15-20% workforce loss. Leaders told us this created operational risk and rostering is being reviewed. They explained a risk assessment has been drafted and will be discussed at risk and compliance group meeting in April 2026.

Nurse staffing levels were reviewed and planned in a timely manner by ward managers. Staff generally reported good levels of staffing and use of bank staffing where there were shortfalls.

During our inspection we saw there were appropriate staffing levels and skill mix allocated to theatres, recovery, and the surgical wards. The actual staffing levels largely met the planned levels.

The trust used the Safer Nursing Care Tool (SNCT) to calculate the number and grade of nurses and healthcare assistants required to manage the acuity of the patients on the wards. This was reviewed by senior nursing staff to help them make decisions regarding safe staffing across the division and organisation. When staffing issues were escalated managers told us they moved staff to where they were most needed within the division. The trust provided data that showed no safety incidents had been reported in the last 3 months because of staffing levels not meeting the service need.

Regular staffing level reviews were undertaken to ensure staffing levels remain safe. Leaders told us that following a recent review staffing numbers on Elm Ward and the Surgical Assessment Unit (SAU) had been increased.

Physiotherapy and occupational therapy services were provided to the surgical division. The general surgery team provided Monday to Friday support to patients that had surgery and had complex rehabilitation needs. Patients being stepped down from critical care were reviewed by a weekend therapy team as appropriate. The orthopaedic team provided a Monday to Friday service and aimed to cover a Saturday service with bank staff. These teams worked with the wider multi-disciplinary team (MDT) to support with discharge planning.

Staff appraisal rates for the surgical division were below the trust target of 90% as of February 2026. For medical staff the rate was 82%. For other staff groups the rate was 77.7%.

The evidence showed some shortfalls. The service did not always assess or manage the risk of infection.

During our inspection we observed a patient mattress that was soiled and contaminated with bodily fluids but was being prepared for use. This posed a significant infection transmission risk. We highlighted this to senior staff who took action to remove the equipment from service. Leaders told us they did not routinely monitor mattress integrity.

The trust provided staff with infection prevention and control training. Nursing staff training compliance was 79%. Medical staff training compliance was 72%. Allied health professionals training was 50%. We did not see an action plan to improve compliance.

The wards we inspected appeared visibly clean. Cleaning records were up to date and demonstrated that all areas were cleaned regularly. Cleaning audit data for December 2025 showed that Denver and Elm wards scored 94%, this is below the trust target of 95%. Sandringham and Feltwell wards achieved 98% and 97% respectively. Where the trust target was not met a re-audit was completed within 24 hours and showed action taken to rectify concerns. Audit data for January 2026 showed all surgical wards achieved the trust target. Data for February 2026 showed all surgical wards achieved the target with the exception of Feltwell ward that scored 94% but passed when re-audited.

We observed equipment being cleaned after each patient contact. We observed staff following Infection Prevention and Control (IPC) principles, including the use of personal protective equipment, effective handwashing and being bare below the elbows.

Hand hygiene signage was displayed throughout the wards. All waste and clinical specimens were observed to have been managed appropriately.

Cleaning records for operating theatres were seen and up to date. Where disposable curtains were used these had a recent replacement date displayed.

Leaders told us they had a number of initiatives to promote infection prevention and control. These included an initiative to reduce the use of gloves when not clinically necessary. We saw promotional material and evidence of discussion at relevant meetings; however, staff we spoke to were not aware of the initiative or its impact.

The evidence showed some shortfalls. Medicines and treatments were not stored safely.

The trust provided mandatory training for medication management to staff. Data from January 2026 indicated compliance with this training was a concern with 14 out of 27 staff groups in the surgical division not meeting the target completion rate. Leaders told us mandatory training was discussed within the division at relevant meetings. No medication incidents had been reported for the last quarter, but this does not mitigate the gaps in staff training.

Medication storage rooms on the wards we inspected had security keypads on the doors. The cabinets within the room had locks but these were not used. This posed a security risk and we were not assured medications were being stored securely.

Medication requiring storage in a cooler environment was kept in fridges. Staff on the wards we visited did not monitor the temperatures consistently. Some staff told us they thought the temperatures were monitored centrally and some told us they monitored them on the wards. We were not assured medications were stored safely.

Controlled drugs (CDs), which were controlled under the Misuse of Drugs legislation (and subsequent amendments) were logged and followed the trust policy. Leaders had identified concerns around CD drug record keeping, expired CD drugs not being returned to pharmacy and discrepancies in oral liquids greater than 5% of total volume, which is outside expected tolerance. A training session was arranged for April 2026.

Liquid medications did not have opening dates recorded. Trust policy indicated that liquid medications should have an opening date recorded.

Patients told us they received information about prescribed medication and had the opportunity to ask questions about them. Patient records we reviewed showed patients’ pain levels were assessed and patients we spoke with told us their pain was managed appropriately. We saw in records that patients had been prescribed and administered pain relief.