Queen's 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

The inspection identified several areas requiring improvement across aspects of safety, including safe systems and pathways, staffing, and medicines optimisation. While the service had made progress in specific areas and completed all required actions from the previous inspection, some related concerns, such as delays in triage and the consistent application of governance practices, were observed again, suggesting a need for continued focus to fully embed improvements and maintain high standards of care.

A developing culture of openness and learning was observed, with staff feeling comfortable raising safety concerns. The service demonstrated commitment to learning, with immediate actions often taken in response to incidents and safety briefs used to share lessons across teams. However, delays in formally closing some incidents and inconsistent attendance at reflective reviews limited the timely embedding of some improvements and reduced the impact of structured governance processes.

Severe access and flow issues persisted, leading to delays in triage, labour wards, and postnatal care. These bottlenecks resulted in patients experiencing prolonged waiting times and, in some cases, self-discharging without receiving care.

The service faced staffing challenges, particularly due to high sickness rates and fluctuating acuity levels. Staff were often redeployed in response to these pressures, which at times impacted continuity of care. However, the service had structured oversight processes in place, including use of the BirthRate+ Acuity tool and daily safety huddles, and was actively reducing vacancy rates and strengthening workforce resilience through ongoing recruitment. Medical staffing challenges further exacerbated delays in patient reviews, although recent measures to introduce dedicated obstetric cover showed potential for improvement.

While most areas met cleanliness standards, issues such as mould, dirty equipment, and non­adherence to uniform policies posed infection risks.

Medicines storage and emergency readiness were strong points, but risks related to the paper-based prescribing system and delays in medication administration remained significant concerns.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service demonstrated a developing culture of safety and learning, characterised by openness, transparency, and a commitment to continuous improvement. Staff consistently reported feeling comfortable raising safety concerns, confident that they would be treated with compassion and understanding, without fear of blame or negative repercussions. This supportive culture encouraged proactive identification of risks and reporting of safety incidents and near misses.

Staff knew how to report incidents and demonstrated awareness of the types of events requiring escalation. Incident reports showed that immediate risks were often addressed promptly. While the potential for harm was not always fully detailed in initial reports, the service had structured processes in place, including daily senior safety huddles and multidisciplinary reviews, to agree harm levels and ensure consistency in learning and follow-up. Incidents were generally managed well, with evidence that immediate actions were taken where necessary to address identified risks. However, safety incidents were not consistently reviewed and closed within the trust's 20-day target, limiting the pace at which lessons learned were embedded into practice. At the time of inspection, there were 57 open incidents, and while immediate actions were evident in some cases, delays in closure reduced the effectiveness of the service's safety governance processes.

Safety briefs were observed at the start of every shift across all clinical areas. These included lessons learned from recent incidents and complaints, providing staff with practical reminders and reinforcing good practices. This was supported by ongoing communication through staff newsletters and safety bulletins. For example, feedback from a complaint about communication during patient handovers led to the introduction of enhanced training on the structured communication tool SBAR (Situation, Background, Assessment, Recommendation), helping to ensure more effective handovers.

Staff had a good understanding of the duty of candour and applied this when things went wrong, ensuring transparency with women and their families. Investigations into incidents included involvement from families where appropriate, promoting openness and building trust in the service.

The service demonstrated examples of positive learning and improvement, but some staff raised concerns about the sustainability of changes made in response to safety incidents. A more structured approach to follow-up on lessons learned could enhance the embedding of improvements over time.

Freedom to Speak Up arrangements were well established, with staff able to access support to raise concerns. The Freedom to Speak Up Guardian was seen as accessible and effective in resolving safety-related issues.

The service experienced significant operational pressures during the inspection, particularly affecting care continuity across clinical areas. While these pressures contributed to delays and required escalation, the service had proactive systems in place to manage safety, including acuity monitoring, daily operational reviews, and flow coordination mechanisms. These processes supported early identification of risk and facilitated responsive decision-making during periods of high demand.

Access and flow were challenged across the maternity unit, leading to delays in triage, labour ward, and postnatal ward. On the day of inspection, the triage area was heavily impacted by high acuity, limited availability of doctors to review patients, and a lack of beds in other clinical areas to transfer patients to. Patients in triage experienced prolonged waiting times, often extending for several hours

The challenges in triage were compounded by blockages throughout the unit. Labour ward capacity was at its limit, preventing transfers from triage and the antenatal ward. Similarly, postnatal ward capacity issues delayed the transfer of patients who had delivered in labour ward, resulting in the entire unit being bed blocked. This lack of movement across the service negatively impacted the timeliness and continuity of care.

Care and support were not always planned and organised safely. During the day shift, high acuity levels were managed by a bed manager who provided a broad oversight of the unit. However, forward planning for the night shift was insufficient, and high acuity continued without the same level of oversight. The service's night staffing model included two band 7 midwives on the labour ward, one of whom was supernumerary with responsibility for unit-wide oversight. During the inspection, inspectors noted that one of the band 7 midwives was required to undertake clinical activity due to high acuity. After the inspection the trust told us staff escalated the issue to the on-call senior manager and they could deploy additional support from the community midwifery team, in line with its escalation policy.

We observed staff following the service's escalation policy, including calling in the manager on call during periods of increased acuity. While these measures provided some immediate support, they did not fully address the underlying systemic issues affecting the safety and continuity of care.

Policies and processes for managing safety and continuity during transitions were not consistently effective. For example, delays in referrals, admissions, and discharges exacerbated the challenges of ensuring a seamless care journey for patients. While staff demonstrated awareness of the escalation policy and adhered to it, when necessary, the broader approach to proactive planning and risk management was not sufficient to prevent or mitigate delays and capacity issues.

The service demonstrated a strong understanding of safeguarding and was committed to protecting people's rights to live safely, free from abuse, harassment, discrimination, avoidable harm, and neglect. It worked collaboratively with partners to ensure safeguarding concerns were identified and addressedpromptly and appropriately. However, confidentiality of sensitive information was not always maintained.

Staff at all levels received training on recognising and reporting abuse, tailored to their roles. Nursing and midwifery staff achieved 89% compliance with adult safeguarding level 3 training and 93% compliance with children's safeguarding level 3 training. Medical staff achieved 90% compliance in both adult and children's safeguarding level 3 training, meeting the trust's target of 90%. Staff were aware of how to contact the safeguarding team, and safeguarding leads were readily accessible for support and guidance.

We observed safeguarding concerns being appropriately discussed during handovers and documented within electronic patient records. Safeguarding issues were included as part of the daily clinical handovers, ensuring staff were aware of any potential risks and the actions required to mitigate them. However, during one observed handover, the handover room door was left open, and safeguarding information could be overheard in a corridor accessible to patients, visitors, and their families. This posed a risk to confidentiality and highlighted the need for vigilance in safeguarding sensitive information.

The service effectively supported staff in identifying and addressing safeguarding concerns. Staff knew how to make safeguarding referrals and liaised with other agencies to protect vulnerable adults and children. Safeguarding processes included recognising the needs of individuals with protected characteristics under the Equality Act 2010, ensuring a non-discriminatory approach to care.

Policies and practices to protect vulnerable people, such as the baby abduction policy and associated drills, were in place and adhered to. Staff demonstrated an awareness and knowledge of their responsibilities under the Mental Capacity Act 2005, ensuring human rights were upheld in decision-making processes.

The service emphasised a collaborative approach to safeguarding, working closely with external partners to provide a robust response to potential risks. This partnership approach ensured that safeguarding systems and processes were effective and well-coordinated.

The service did not consistently work with people to understand and manage risks in a way that was safe and supportive. Significant issues persisted with risk assessments, particularly for patients attending triage or admitted as inpatients. While antenatal appointments demonstrated consistent completion of risk assessments, this was not the case in the triage area or during inpatient admissions.

Patients attending triage were not always risk-assessed within the timeframes outlined by the Birmingham Symptom-Specific Obstetric Triage System (BSOTs), which the service had adopted. BSOTs stipulates an initial midwife review within 15 minutes of arrival, followed by a RAG (red, amber, green) rating to prioritise obstetric reviews. During this inspection, delays were observed in both the initial 15-minute assessments and subsequent obstetric reviews for all RAG ratings. These breaches occurred during a period of high attendance and reduced obstetric cover, which the service attributed to temporary redeployment of staff to manage clinical acuity elsewhere. While the trust had processes in place to escalate and mitigate such pressures, the shortfall on the day impacted timely triage reviews. These delays contributed to instances where patients self-discharged before receiving appropriatecare. Immediate actions were taken by the service to strengthen triage staffing and improve the timeliness of assessments.

Some patients reported not being provided with food or drink during these extended periods and expressed frustration at not being informed of the expected wait times. We observed a concerning trend of patients self-discharging due to the delays in being reviewed by medical staff, potentially placing them at risk of harm.

Venous thromboembolism (VTE) risk assessments are essential for identifying women at risk of complications. Audit data provided by the service demonstrated that VTE risk assessments were consistently completed across maternity wards, with compliance regularly exceeding the trust's 95% target. However, we saw records that indicated some elements, such as confirmation of when compression stockings were prescribed and applied to reduce the risk of blood clots, were inconsistent.

The service audited compliance with cardiotocography (CTG) monitoring, which includes hourly dual-clinician `fresh eyes' reviews in line with national guidance. In September 2024, audit data showed a compliance rate of 82%, which exceeded the national benchmark of 80% but was below the trust's internal quality improvement target of 90%. While improvements had been sustained over the past year, the service continued to implement measures to further enhance consistency, including the reintroduction of CTG champions, weekly huddles, and strengthened support from the fetal surveillance team.

Access and flow issues continued to impact safety and timely care. Labour wards could not accept patients from triage or antenatal wards due to capacity constraints, and postnatal wards faced delays in transferring women from labour wards. These issues caused widespread bed-blocking across the unit. On the day of inspection, patients were observed waiting in triage for extended periods, some without access to food or drink, and with limited communication about expected wait times. These observations raised concerns about patient comfort and experience during high-demand periods.

The service did not always ensure that the environment and equipment supported the delivery of safe and effective care. Facilities were not always well-maintained, and some areas presented risks that could impact patient safety.

Corridors in the labour ward were cluttered with boxes of stock and beds obstructing access to theatres, creating potential delays during emergencies. The trust acknowledged this issue during the inspection and committed to introducing a system to manage stock levels and ensure safe storage away from corridors. Similar issues were highlighted in the previous inspection, and no sustained improvements had been made.

Furniture in certain areas was not well-maintained, particularly in the bereavement room, which had scuffed and damaged furnishings. Additionally, the room was not soundproof and was situated adjacent to a delivery room. This exposed bereaved families to the sounds of labour and newborns, which detracted from the dignity and privacy required for those experiencing pregnancy loss.

Security measures were in place to ensure safety of patients and babies. However, while the trust had measures such as wristbands for birth partners and discharge slips to mitigate baby abduction risks, these were not consistently implemented, particularly overnight, when ward clerk coverage was unavailable. Clinical staff were required to cover administrative roles during these hours, reducing their ability to monitor security effectively. This gap was recognised by the trust and had been recorded on the risk register, with mitigation strategies in place and ongoing oversight through the trust's governance process. A security code access system was in place across maternity ward entrances; however, we found that the link door between the antenatal and postnatal wards allowed unrestricted access between the two areas.

In contrast, the labour ward had 24/7 ward clerk coverage, and secure exit measures were observed during the inspection. Post-inspection, the trust reported further improvements, including replacing the labour ward's push-button exit system with an access control panel and intercom.

During the inspection, staff members reported concerns about the availability of monitoring equipment, such as sonicaids and tocodynamometers, which they felt contributed to delays in care. After the inspection the trust told us no formal incident reports relating to equipment shortages were submitted during the inspection period. The trust said all required items were available and appropriately distributed across clinical areas.

While staff adhered to infection control measures, including using personal protective equipment (PPE) and cleaning equipment after use, the cluttered environment in some areas hindered efforts to maintain a safe and hygienic setting.

The service conducted regular baby abduction drills, with the most recent in July 2024. These drills were used to identify learning points and implement necessary actions.

The service did not consistently ensure there were enough qualified, skilled, and experienced staff to provide safe, high-quality care. While efforts were made to maintain safe staffing levels, such as redeploying staff and using bank and agency staff, this approach often resulted in gaps in coverage across some areas.

The service's vacancy rate was 10% which met the trust target of 10%, however, we observed, and staff reported, persistent challenges with staffing levels and skill mix. Staff reported that they were frequently redeployed to cover shortfalls, particularly during night shifts, leaving areas such as triage, the antenatal ward, and the birth centre short-staffed. This included the High Dependency Unit (HDU), where there was not always midwifery cover despite its antenatal and postnatal patient population requiring midwifery expertise.

Staff reported feeling stretched and raised concerns about the impact of redeployment on patient care. The trust acknowledged the shortfalls and highlighted an ongoing recruitment drive and plans to train more midwives for HDU. Bank and agency staff were used to support the service, but their numbers were insufficient to fill all gaps consistently.

Medical staffing also presented challenges, with delays in obstetric reviews observed during the inspection. These were associated with the demands placed on triage doctors, who also provided support across the wider unit, limiting their availability for continuous review in triage. While the trust had in-hours consultant and registrar presence, this was not always sufficient to ensure timely reviewsduring periods of high activity. Following the inspection, the trust introduced 24/7 resident-level doctor cover in triage to strengthen responsiveness and improve flow.

Sickness rates were consistently above 5%, with 7.2% in July 2024, 5.5% in August 2024, and 6.31% in September 2024. This posed additional challenges and, as confirmed by the trust following the inspection, exceeded the internal target of 3.6%.

Staffing challenges, including midwifery shortfalls and staff redeployment, were identified during the previous inspection. These continued to be a concern during this inspection, alongside newly observed pressures on medical coverage. Although some measures, such as the recruitment drive and increased triage medical coverage had been implemented with positive impact, we observed gaps in staffing across several areas, and staff reported feeling stretched. The medical appraisal rate remained below target, showing no progress from the prior inspection.

Despite the staffing challenges, staff reported having access to relevant training and learning opportunities. Managers supported professional development, and staff felt that training provided was appropriate for their roles.

Nursing and midwifery staff appraisals were at 93%, exceeding the trust target of 90% and representing an improvement from the previous inspection. The trust also confirmed that 92% of eligible medical staff in the obstetrics and gynaecology department had completed an appraisal within the preceding 12 months. The remaining staff members were known to the trust, and their appraisal status was being actively managed in line with policy, reflecting oversight of compliance across staff groups.

The service did not consistently assess and manage the risk of infection, which left people at potential risk. Although most clinical areas inspected were visibly clean and hygienic, there were exceptions that raised concerns.

While the majority of the clinical areas inspected met expected cleanliness standards, some issues were observed. A bathroom in the bereavement room had visible mould, and the fridge in the same room appeared dirty despite regular completion of cleaning checklists. This raised questions about the effectiveness of cleaning practices and the robustness of checks carried out.

Staff were not consistently adhering to national infection control guidelines or the trust's uniform policy. Observations included staff in clinical areas wearing wristwatches, gel nails, and leaving hair down. These practices are not in line with the trust's policy, which mandates that hair must be worn off the collar, fingernails must be short and clean without nail varnish or extensions, and staff must be bare below the elbow. These breaches could increase the risk of infection transmission and undermine the overall infection prevention strategy.

The service did not consistently ensure that medicines and treatments were managed and administered safely. While certain aspects of medicine management met expected standards, there were significant areas requiring improvement to ensure patient safety and compliance with best practice.

Medicines were securely stored in line with best practice, with staff having access to suitable spaces for preparation using aseptic techniques. Emergency medicines were readily available and checked daily to ensure they remained safe for use. Fridge temperatures in clinical areas were monitored regularly, and staff took appropriate action when readings were out of the recommended range.

The service used a paper-based prescribing system, which was found to have significant risks associated with its management. Patients were issued with a single prescription chart throughout their pregnancy, which included entries from multiple inpatient admissions. This practice resulted in outdated or no-longer-appropriate medications remaining listed without being crossed out, increasing the potential for medication errors.

Further, prescribing duplication was observed, where medications were written both as STAT (immediate) and as part of regular medication regimens, resulting in instances of overdosing. These issues highlighted weaknesses in the service's oversight of paper prescribing systems, which were not in line with best practices.

Patients we spoke to reported delays in receiving their medications and indicated that they had to remind staff about administering doses. These delays could compromise treatment efficacy and patient trust in the service.

The trust reported plans to implement an electronic prescribing system in 2025, aimed at mitigating risks associated with the paper-based system. Additionally, a maternity-specific medicines improvement workstream was launched to address these and other concerns.