The Queen Elizabeth Hospital

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• 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 rated this key question good. At this assessment the rating has changed to requires improvement. This meant people’s needs were not always met.

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.

We scored the service as 2. 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.

Care plans were reported by staff to be reviewed daily; however, our review found they were frequently incomplete or did not accurately reflect assessed needs. Pain assessments were not completed in line with trust policy. For example, all 5 care plans reviewed lacked the required 4 times‑daily pain scoring, and 1 patient with a recorded pain score of 7 did not have this reflected in their care plan. We also found a patient with a pressure ulcer whose care plan stated an air mattress was in use, but this was not in place, indicating care was not delivered in accordance with the documented treatment plan.

Patients we spoke to told us they were not always aware of the details within their care plans to ensure they were at the centre of their care and treatment choices. During our assessment, we did not see a record of any conversations with patients with regards to the pressure ulcer risk assessments when risk was identified.

Patients were not always placed in the correct areas to support with their additional needs, for example outlier patients were not on speciality medical care wards, frailty beds were used to bed step down stroke patients which meant that frail elderly patients were not placed in the optimal ward for their care needs.

Ward rounds were conducted Monday to Friday and gave patients and their relatives opportunity to understand their diagnosis and treatment. Patients told us that they were supported and encouraged to ask questions.

Patients were given a choice of foods and options were reflective of their dietary or cultural preferences. For example, staff worked with the housekeeper to ensure finger foods were available for a patient that was unable to use a fork and knife.

The palliative care team supported patients and staff to discuss and make decisions about place of care when they were identified as approaching end of life. These were documented within care records.

Specialist support was not available at weekends due to staffing and funding. For example, the palliative care team provided a Monday to Friday face to face service but at weekend and out of hours this was provided over the telephone which the service felt could result in delayed decision making.

Ward therapists discussed and identified specific needs and reasonable adaptations prior to discharge with patients and their families.

We scored the service as 2. 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, so care was not always joined-up, flexible or supportive of choice and continuity.

The division acknowledged that they were not collecting robust data sets to understand the health inequalities within their division. They had started to attend meetings to understand the wider health inequalities of the local population as divisional leaders, but more work was needed to ensure care was joined-up, flexible or supportive of choice and continuity.

The trust used health passports such as ‘This is me’ as a support tool to enable person centred care, choice and continuity. The division did not audit the use and completion of these in order to understand compliance rates, and identifying if there was a need for better caregiver involvement and staff training. Divisional leaders told us they intended to complete a dementia trio audit every 6 months which would include auditing the ‘This is me’ passport.

During our onsite assessment, there had been ward moves whilst essential estate works were being carried out to specialist wards to support the delivery of care. Staff told us that had an impact on them and the service. For example, there were not enough side rooms on the temporary ward for oncology patients and where there was an increase in bed capacity staffing uplift was filled using bank staff. These shifts were not always filled which meant that staff felt stressed. The hospital was reviewing their safer staffing model to ensure that they had the correct number of staff for areas based on acuity.

Patients had access to specialist services; however, these were not always available at the weekends. For example, diabetic patients who were admitted on a Friday were not reviewed by a specialist nurse until Monday. This was due to there not being enough specialist nurses within the team. Tracking of patients was manual for some speciality services which meant that it was difficult for nurses to track patients and ascertain the unmet needs easily and those that required follow up. The hospital did not have digital systems or one system to manage patients. This prevented quick access to information by community partners and internal teams.

The specialist nurses had close links with the Norfolk Community Health & Care teams who supported in reaching such as the Chronic obstructive pulmonary disease (COPD) and heart failure team. This optimised people at home to avoid unnecessary admissions where possible.

Some community services were not available in areas which meant that there was an increased workload for staff and unnecessary length of stay for patients. For example, there was a lack of commissioned home oxygen services in Cambridgeshire. This meant that care was not always supportive of choice and continuity.

The service met with the integrated care board (ICB), commissioners and other local services to discuss care pathways and provision of medical care. These included lung cancer improvement pathway and West Norfolk palliative care group.

There was a total of 139 incidents related to treatment and admission delays in the last 12 months. We were not informed of how the division were planning on addressing issues such as a lack of stroke beds. The risk was included in the divisional risk register.

The complex discharge team held daily and weekly meetings with external partners to identify barriers to early discharge and to commission beds for patients to facilitate transition and continuity. For example, a joint meeting was held to support a patient that had multiple reattendances which resulted in more supportive, consistent and collaborative management was put in place.

There was a dedicated frailty telephone line available until 7pm Monday to Friday. This provided ambulance services with real-time access to geriatricians and specialist clinicians to share patient backgrounds and collaboratively create safe, at-home care plans to avoid unnecessary hospital admissions for older, vulnerable patients.

We scored the service as 2. The evidence showed some shortfalls. The service did not always supply appropriate, accurate and up-to-date information.

Ward rounds gave patients and their families opportunity to gain information about their care and treatment. However, there were recurrent complaint themes within the division in relation to lack of communication and review of reported incidents showed that patients and relatives did not always get timely information such as test results and 12 open incidents related to a breach of patient confidentiality.

Information leaflets were available for some conditions and procedures. For example, gastroscopy and colonoscopy leaflets explained benefits, risks and details of the procedure. Staff within endoscopy told us that they could have information leaflets made in languages spoken by patients if required.

Specialist teams met with patients and their families to help them understand their prognosis and likely outcomes from treatment.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They did not always involve people in decisions about their care or tell them what had changed as a result.

Emergency Care and Medicine (ECAM) and Endoscopy received 210 formal complaints between April 2025 and March 2026. Where complainant was not happy with the outcome of the trust’s investigation, they were able to take this to the Parliamentary and Health Service Ombudsman (PHSO). We were told that 3 complaints were escalated to the PHSO in the last 12 months, we were not told if these were upheld.

Patients we spoke to did not always know how to raise concerns but told us they would speak to the nurse that cared for them.

The division collected patient feedback through number of ways such as friends and family test (FFT), reviewing patient complaints and patient forums. We requested feedback results for medical care; however, this specific data was not available. Completion of the survey results were below the target for most of the wards. This meant that the division would not be able make changes in response to patient feedback that was representative of those accessing care.

Review of April 2026 governance meeting minutes showed that there has been no representative from the complaints team and response compliance was 62% for closing within 30 days. This meant that there was a delay in identifying where care had not met expectation and what had changed as a result.

Divisional leaders shared evidence they had responded to feedback and complaints. For example, in they had opened Peddars Way unit which was a dedicated unit for palliative care patients who choose to remain in hospital during their last days of life. The Values and Behaviours training was revamped, and this was a mandatory requirement due to concerns raised around poor communication by staff.

Staff told us the lack of reception staff meant clinics did not gather patient feedback to drive improvement. A lack of dedicated teaching areas to hold patient education groups meant venues were sourced externally requiring additional finance to set up educational groups for patients.

There was some evidence of ‘you said, We did’ on medical wards to demonstrate action taken, for example patients reported struggling to sleep, the ward switched to decaf tea and coffee on West Newton Ward in March 2026. This was not consistent across all medical wards to demonstrate action being taken to address patient and family feedback.

The hospital had displayed Martha’s rule posters in all ward areas to empower patients, families and staff to escalate any concerns. The division was yet to role out a pilot project to trial asking patients if they had concerns about their care and treatment

We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure that people could access the care, support and treatment they needed when they needed it.

Patients were not always placed on wards most appropriate to their needs due to bed capacity and a lack of community provision available. For example, there were medical outliers on surgical wards that may come to harm as they were not being reviewed in a timely manner delaying investigations and treatments. These were not incident reported by staff which meant that the division could not be assured that patients had not come to harm or if discharges had been delayed.

Staff told us that outlier patients did not have a named consultant and this led to delays in care and timely reviews. Divisional leaders told us that they had a rota in place for a named consultant allocated to all medical outlier patients to allow for wards and medical staff to mitigate this risk.

Patients could not access specialist care and treatment over the weekends due to a lack of funding and staffing provision. For example, ward therapists were not available on wards over the weekend to provide rehabilitation and timely assessments across all medical care wards. The provision of weekend therapy was covered by bank staff which meant that there was no consistent access for all medical care wards.

Frailty beds were being used by the stroke step down patients which meant that elderly patients were not cared for by consultants and nurses trained in frailty care and on wards that were designed to support them.

Timely speciality reviews were not carried out upon referral in the emergency department and wards which meant that patients were waiting longer for admission or advice impacting on care.

Staff planned for patient’s discharge, however, expected discharge dates were not consistently reviewed at morning board round. Therapy staff told us that staff were not always able to support rehabilitation goals on the ward due to low staffing. This meant necessary arrangements to support a timely and safe discharge were not always made.

During our assessment there was no formal referral process in place to refer to the rehabilitation services. Divisional leaders told us it was anticipated it would be implemented in June 2026 in line with the other acute trusts within the Norfolk and Waveney Group. This would mean there would be a consistent approach for referring patients requiring occupational and physiotherapy services. The service did not collect data on this.

There were systems in place to review consultant referral to treatment times (RTT). We spoke with senior leaders who told us that their largest RTT wait times were in relation to cardiology. Weekly patient tracking list (PTL) meetings were held to review waiting times for patients. Action had been taken to reduce wait times for some speciality areas such as extra clinics and an echo room on the cardiology ward. We were told that clinicians would retrospectively incident report any harm experienced once seen at their appointment.

We asked divisional leaders if harm reviews were completed for patients that were waiting for appointments and we were told that these were not completed. We were not assured that patients on the waiting list were not coming to harm whilst awaiting new appointments or follow-up appointments.

During our assessment we requested inpatient speciality referral data to review if patients were accessing care and treatment in a timely manner. We were not provided with this data; therefore, we were not assured that patients were accessing care and treatment when they needed it.

We requested data on incidents relating to delayed admission or treatment and found 139 treatment delays within ECAM. Of these, 48 incidents related to delays in the implementation of care, including delays in being assessed by a clinician, and a further 41 incidents related specifically to delays in clinical assessment. There were 17 incidents involving delays to patient admission, all of which related to stroke admissions. These findings indicate ongoing risks to timely access to assessment and treatment.

Staff made reasonable adjustments for patients, for example, people with mobility issues were provided with walking aids.

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 the care and treatment of patients. However, evidence reviewed in care records showed that this was not always timely and in response to identified risk.

We scored the service as 2. The evidence showed some shortfalls. Staff and leaders did not always act or gather information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

Patients did not always have equity in experiences due to services not being available over the weekend. For example, clinical governance meeting minutes highlighted that specialist palliative care services were not fully funded to support a 7-day service. The team was not funded sufficiently to support a robust 5-day service and meet the demand within the division due to a reliance on the team.

The stroke service did not have a sufficient bed base and therapy provision in line with national guidance. Sentinel Stroke National Audit Programme (SSNAP) data showed that patients were not always receiving the recommended therapy provision which could impact on functional outcomes.

Medical staff told us that referral to specialist consultants were often delayed due to inconsistent referral pathways and poor culture. The triumvirate leaders did not monitor interprofessional standards relating to speciality reviews to monitor equity in experience and outcomes.

Medical outlier patients on surgical wards were not cared for by nurses with medical‑specialty training. Staff told us they were sometimes uncertain about investigations requested by the medical team, which led to delays in completing required tests and interventions.

The division worked with community partners to improve experience and outcomes for patients. For example, the trust worked in partnership with social services to support timely discharge patients. This resulted in a more streamlined referral process and reduced delayed discharge for patients from 8 days to 2 days for patients residing in the Norfolk area.

The provider had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage.

The Trust was also a member of the NHS Anchors Network across Norfolk and Suffolk, a system-wide forum bringing together NHS providers and the ICB to collaborate on health inequalities, share approaches and drive collective action.

Staff were trained in equality, diversity, inclusion and human rights, compliance was 94.4% for the division.

Equality impact statements were applied to trust policies to ensure policies do not inadvertently discriminate against specific groups and actively promote equality.

We scored the service as 3. The evidence showed a good standard. People were supported by planning for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff supported patients to make decisions about their care and treatment and their future. We reviewed 16 care records for completion of Recommended Summary Plan for Emergency Care and Treatment (ReSPECT). We found that 13 were completed in line with trust policy. We requested audit compliance for the last 6 months within the division. We were told that there was no target for compliance historically. Audit data showed that there was a lack of completion of mental capacity assessments to support decision making where a patient lacked capacity and a decision was made in their best interest. Divisional leaders told us they planned to allocate role-specific reader and writer trainer and set a target for the completion of ReSPECT forms.

The Peddars Way Unit was available to support the care for people who are nearing the end of their life were managed and communicated in a sensitive and dignified way. In February 2026 there were 79 deaths reported within the ECAM division, 30 of these were within the Peddars Way Unit suggesting that there was timely recognition of the dying patient.

The palliative care team were available 5 days a week to support the wards, patients and their families to plan for end-of-life care. Clinical governance meeting minutes showed that the team establishment and funding covered 3 days per week which was not sufficient to meet the demand within the division. Although there was no evidence of harm coming to patients, there was an acknowledgement that this impacted staff morale.

The weekend and bank holiday service comprised of a telephone advice line for clinicians which can be accessed 24 hours a day for advice and operates from the Norfolk and Suffolk ICB. The palliative care team kept a register of patients and were alerted by the hospital system if a patient was admitted. This system allowed for the team to proactively review and respond to patients.

Advanced care plans for the last days of life were used to focus on the person's needs, preferences, and wishes, ensuring comfort, dignity, and support for both the individual and their loved ones. These documents were held within yellow folders for staff on the ward to allow for easy identification of patients that were end of life.