Queen Alexandra 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

At our last assessment we rated this key question Good. At this assessment the rating has remained good. This means we looked for evidence that people were protected from abuse and avoidable harm.

The service was in breach of legal regulation in relation to staffing (training).

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice

Trust policies and procedures gave staff guidance about reporting, managing, investigating, and learning from incidents. The trust’s incident reporting and management policy was published on their website and met the requirements of the National Patient Safety Incident Response Framework. The Patient Safety Incident Response Framework (PSIRF) is focused on learning from incidents to provide safer care to patients. Following the requirements of the PSIRF, the trust published their Patient Incident Response Plan on their website. Following their analysis of reported incidents, the trust identified patient safety priorities for the next 12 to 18 months and outlined how they would respond to them. This included responding and making improvements in relation to the management of pressure injury, infection control, medication incidents, inpatient falls, mental health and maternity incidents. The medical services division completed a local safety profile and identified the most frequent incidents reported were pressure ulcers, patient falls, medication errors and violence and aggression from patients. Information provided by the medical service, including minutes from meetings and discussions with staff, demonstrated the service was aware of the priorities, kept them under review and took action to make improvements.

Between 1 November 2024 and 1 May 2025 across the medical and older persons medicine services and the acute medical unit a total of 4,595 incidents were reported. Of these, 17 resulted in severe harm to the patient and 15 were reported a harm level of death. The highest number of incidents were patient slips, trips and falls (1098), tissue damage (1,122). The trust patient safety incident plan had identified these as areas for improvement.

Review of incident investigation reports provided by the service, showed areas for learning and improvement were identified and action plans were developed. Action plans had clear timescales for completion of actions with a designated responsible person or group. The service provided evidence that Duty of Candour was carried out. The Duty of Candour legislation requires healthcare organisations, including hospitals, to be open and honest with patients when things go wrong during care. This means being transparent about what happened, offering an apology, and explaining any investigations or actions being taken. It ensures patients are informed and involved in the process of addressing the incident. Records provided by the service showed patients and relatives received both written and verbal duty of candour information about the incident and the outcome of the investigation. However, the information provided showed that the service did not always offer the opportunity of a meeting with patients and/or their relatives to discuss the findings of the investigation. This is an area where improvements could be made.

Staff we spoke with understood the patient safety incident response framework. They knew what incidents they needed to report and how to report them. Multiple processes were used to share learning from incidents with staff. This included handover headlines, Share, Learn, Improve learning from safety incidents newsletter and staff huddles. Examples of learning from incidents included action plans for improving pressure ulcer prevention, ensuring the ‘This is me’ documents were provided to patients’ next of kin to complete and reminders to staff to ensure care plans were personalised to meet patients’ individual needs.

Morbidity and Mortality meetings were used to identify any learning from patient outcomes. The trust’s Learning from Deaths Policy gave guidance about what deaths must be reviewed, about the management of morbidity. Mortality meetings including who should attend, frequency of meetings, and what the outputs of the meeting should be, for example learning for clinical practice. Review of morbidity and mortality meeting records provided by the service demonstrated staff identified areas for learning.

The trust had a process for responding to central alerts about safety, which included processes for notifying the medical services about national safety alerts. Between 1 November 2024 and 1 May 2025, the medical service had not received any external safety alerts specifically for them to action, but they had been included for information on 6 national alerts.

We scored the service as 3. The evidence showed a good standard. Although the service experienced significant challenges with patient flow, they worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They acted to ensure there was continuity of care, including when people moved between different services.

Trust wide, there was a policy to support staff to manage patient flow through the hospital safely. However, this meant that patients were cared for and treated in areas in the medical services not designed for patient accommodation and care. Challenges with patient flow through the hospital meant that most medical patients admitted through the emergency department did not have an inpatient bed allocated to them in a timely manner. This meant many spent the first day of their hospital experience in the emergency department and not on a ward. Staff followed processes to ensure patients received the treatment and investigations they needed in the emergency department, so there were no delays to their treatment.

Staff said that due to the patient flow problems, the acute medical unit (AMU) was no longer used as intended. Although, the precise role of an AMU can vary from hospital to hospital, its core functions include the assessment, investigation and stabilisation of patients with an acute medical need and determining the next steps for the patient, which may include discharge with follow-up care or transfer to a specialist ward. The typical length of stay of a patient in an AMU is 72 hours. Staff told us that most patients had already started their care treatment with a specialist medical team before being transferred from the emergency department. This was because they had spent a long period of time in the emergency department waiting for a bed to become available. Staff also said many patients spent more than 72 hours in AMU, with some remaining in AMU for weeks. However, staff statements about patients’ length of stay on AMU could not be corroborated as we did not request data from the service to demonstrate how long patients remained on AMU.

Staff followed trust processes to ensure patients received timely review by consultants once accepted into their specialised care. This is called the post-take review and would normally be carried out on a specialised medical ward once the patient was admitted. Information provided by the service demonstrated they consistently achieved 70% to 80% compliance with the national time frames for post take reviews. However, the same information detailed that most of the post take reviews were carried out in the emergency department. This was due to challenges with patient flow from the emergency department to the medical wards.

The trust had processes and policies to support staff working in the medical services to manage the discharge of patients safely. Observations showed that plans and progress for patient discharges were discussed by the multidisciplinary staff teams (medical staff, nursing staff, therapists, and discharge coordinators) at board rounds. Discussion with senior leaders demonstrated they had identified some ward areas where board rounds did not always support effective and timely discharge planning. They were working with staff in those areas to make improvements.

The hospital had a matron and a team of registered and unregistered staff who supported with the discharge pathways for patients who had complex needs and those patients, such as those who were at the end of their life and wished to die at home, who required fast track discharges. They described there were ongoing challenges with external partner organisations making decisions about which organisation would fund ongoing care for patients with complex care arrangements at their discharge. This increased the number of patients whose discharge was delayed and negatively impacted in patient flow through the hospital.

To support improvement with patient flow through the hospital, the trust was undertaking a trust-wide workstream called Transforming the Take, with one of the areas focused on discharge. The focus was on providing enhanced support to board rounds across all inpatient wards, including medical care wards with a view to improve discharge processes. This work was aligned with the Discharge Standard Frameworks which had been implemented by the ICB and has a set of key performance indicators.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The trust had a safeguarding policy that referenced relevant national guidance. It provided clear guidance about the actions staff needed to take if they were concerned a patient had been subject to abuse and clear guidance about action staff needed to take in the event of an allegation of abuse. The service provided evidence that it referred safeguarding concerns to the local authority,

Policies were also in place to guide staff about the use of restraint and restriction to ensure they were not used inappropriately. This included the legal frameworks for restraint, who could or could not carry out restraint, and the training requirements for people who could carry out restraint. Physical restraint was only carried out by appropriately trained security staff and the police if needed. Our review of the records from the last 6 restraint events demonstrated that least restrictive practices were considered and acted on before restraint was used. The records demonstrated chemical restraint was used, (sedative medicine), and no physical restraint was used. The service reported there had been no incidents of rapid tranquilisation in the 6 months prior to the site inspection.

Staff received training about safeguarding. Data provided by the service showed that staff completed safeguarding training at levels that were relevant to their roles. Most staff groups had reached the trust target group of 85% compliance with safeguarding training.

Staff we spoke with had a good understanding about safeguarding, and knew the actions they needed to take in the event they suspected a patient may have experienced abuse or be exposed to abuse. Staff knew how to contact the safeguarding leads in the trust for advice and guidance.

Staff reported safeguarding concerns to the local authority safeguarding team. In the 6 months prior to the onsite visit, 118 safeguarding adult referrals had been made to external safeguarding services by the service.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks. Staff provided care to meet people’s needs that was safe and supportive.

Staff had access to policies and procedures to support them with assessing risk of harm and deterioration of patient’s conditions. Treatment escalation plans were used by staff to record and communicate patients personalised and realistic goals for treatment, particularly when their condition may deteriorate.

Staff used a nationally recognised tool to identify deteriorating patients and escalate their conditions to medical staff. The National Early Warning Score (NEWS2) was used in the service to identify patients at risk of deterioration. Our review of documents showed staff completed scores correctly. When a concerning score was calculated, the patient was escalated for medical review. Staff demonstrated a good understanding about the use of NEWS2 and when and how to escalate a deteriorating patient to medical staff.

The service monitored compliance against vital signs completion, staff response to deteriorating patients, management of suspected sepsis, management of acute kidney injury and the use of Martha’s rule. However, the service could not be fully assured staff followed the NEWS2 process because they did not monitor or audit the NEWS2 process. This is an area that could be improved.

Data provided by the service showed an improving trajectory for staff completion of patients’ vital signs, (pulse, respiratory rate and blood pressure). Although, the compliance rate did not meet the trust target of 80%, compliance had improved to 79% in March 2025.

Information provided by the service showed that between 1 January 2025 and 31 March 2025, 88% of patients with NEWS2 score 5–6 were seen within 1 hour and 83% of patients with NEWS2 score of more than 7 were seen within 1 hour. However, this did not demonstrate the service had a process that was in line with the Royal College of Physicians National Early Warning (NEWS) 2 guidance. The threshold for triggering a senior medical review was higher in the service than that detailed in national guidance. This detailed that a NEWS2 score of 5 or more was a key threshold that should trigger an urgent clinical review. The document detailed that a NEWS2 score of 7 or more should trigger a high level clinical alert, namely an emergency clinical review and that the response team for this clinical review must include staff with critical care skills including airway management.

The service provided detail of compliance with the sepsis pathway in the medical services. For October, November and December 2024 the service was 100% compliant with the sepsis pathway. For the previous January to March 2024 there had been no episodes of hospital acquired sepsis in the medical services. For those patients admitted to the medical services with community acquired sepsis, their treatment was started by the medical staff in the emergency department.

Systems were in place for patients and their families, friends, or carers to escalate concerns about their conditions. Martha’s rule of detecting deterioration enabled patients and their friends, family, or carers to contact the critical care outreach team if they felt their condition was getting worse and was not being addressed by the staff on the ward. Posters advertising this service were visible on the wards.

Staff completed risk assessments for each patient on admission using nationally recognised tools. This included a range of risk assessments, for example, falls, pressure areas, sepsis, nutrition, and venous thromboembolism (VTE). When actions or plans were required to reduce the level of risk, patient records showed these had been completed.

We scored the service as 2. 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 and facilities supported the delivery of safe care.

The provision of oxygen and suctioning equipment on the acute medical unit (AMU) had the potential to delay access to this equipment when patients required it. In the multiple occupancy bays, there was only 1 oxygen port and 1 suction port between 3 beds. At times when a, Your Next Patient space was used in the multiple occupancy bays, this could mean there was 1 oxygen port and 1 suction port between 4 patients. This was not in line with national guidance. The Department of Health’s Medical Gases Health Technical Memorandum 02-01: Medical gas pipeline systems published in May 2006 recommended 1 oxygen terminal per bed in multi-occupancy bays. Staff raised concerns with the inspection team about a potential risk to patients due to limited access to oxygen if they were not positioned near the oxygen terminal. However, staff did not describe any incidents or harm to patients because if this.

There was no evidence the service had considered any potential risks to patients because of the provision of oxygen and suctioning equipment in the AMU. We requested environmental risk assessments, including the provision of oxygen and suction on AMU wards. Following their receipt of the draft inspection report, the service provided risk assessments for the use of Your Next Patient (YNP) spaces. These included an assessment of the risk associated with no permanent oxygen and suction terminals available for patients accommodated in YNP spaces. However, there was no assessment of potential risk to patients because of the lack of provision of oxygen and suction terminals in the bays in AMU.

Ward environments were generally tidy and free from ‘clutter.’ Staff completed daily safety checks on all specialist equipment including the resuscitation equipment and records of this were completed. Electrical equipment in each ward area had been safety checked and maintained so was safe to use. Most equipment had a sticker attached which detailed when it was next due for servicing.

To reduce the risk of patients using the environment to harm themselves, an annual ligature point environmental assessment was carried out. Ligature cutters were available on the wards and staff knew where to find them.

Most patients could reach call bells to call for assistance. Call bells were positioned by patient beds, but not always in escalation areas. We observed that staff responded to call bells quickly and the noise from unanswered call bells was minimal. Patients said that most of the time staff responded to call bells promptly. However, comments in the Friends and Family Test results indicated that patients accommodated in escalation areas did not always have a tool to call for assistance., they sometimes had to verbally attract the attention of a nurse who walking past them.

Staff disposed of clinical waste safely. Waste was segregated and labelled in accordance with the trust policy.

Staff said they had sufficient equipment to carry out their work safely. This included sufficient infusion pumps, monitoring equipment, moving and handling equipment and IT equipment. However, conversations with staff and information provided by the service indicated there could be some challenges for staff accessing equipment and aids to support patients with a learning disability.

We scored the service as 2. The evidence showed some shortfalls. The service did not make sure there were staff who had the skills and experience to support and provide safe care and treatment to meet the needs of autistic patients and patients with a learning disability. Not all staff received timely appraisals. However, processes were followed to ensure there were sufficient numbers of staff to provide care and treatment to patients and staff received support and development.

The service did not ensure staff had the skills and knowledge to support and provide safe care that met the needs of autistic patients and patients with a learning disability. Not all staff had received training about learning disability and autism. All NHS services are legally required to ensure their staff received training about learning disability and autism appropriate to their role. This was to equip staff with the right skills and knowledge to provide safe, compassionate and informed care to autistic patients and patients with a learning disability. Across the medical care group and older persons medical care group there was a 90% and 94% compliance rate with part 1 e-learning about learning disability and autism. However, for tier 1 training only 40% in the medical care group and 27% in the older persons medical care group had completed the training. For staff who required tier 2 training only 23.7% and 23.2% had completed the training. The service advised that the ability of staff complete tier 2 training was limited by the stakeholder who provided this training. There was no detail about what the service and the trust were doing to influence improved availability of this training.

Following their receipt of the draft inspection report, the service provided updated details about the provision of this training. This demonstrated they were taking action to improve the completion of tier 2 face to face training about learning disability and autism. However, although this showed an improving trajectory for all tiers of this training, compliance rates for tier 1 and 2 remained below 50% and there was no reason given for why the compliance rate for tier 1 training was low.

Staff confirmed they received training and appraisals. All staff completed mandatory training appropriate to their roles. The trust set a target for 85% of staff to complete mandatory training. Data provided by the service showed, that within the medicine care group, 3 out of 11 staff groups did not meet the trust target of 85%. The main group of staff that did not meet the target were medical staff. In the older person medicine care group, 4 out of 10 staff groups did not meet the trust target of 85%. The main group of staff who did not meet this target were ‘other scientific, technical and therapeutic staff. No data regrading completion of mandatory training was provided for staff working in the Acute Medical Unit. Improvements were still needed in staff compliance with mandatory training.

Managers calculated the number and grade of nurses and healthcare assistants required. The service used a nationally recognised safe staffing tool to calculate the number of nursing and healthcare support works required to ensure there were sufficient staff to meet the acuity and needs of patients on the wards. Using the tool and professional judgement, the service reviewed staffing level requirements twice a year and made recommendations to the trust board about staffing requirements.

Planned and actual staffing numbers were displayed on wards. It was observed that not all wards met their planned staffing numbers. Staff said that often staff were moved to other wards to lessen risk of insufficient staffing.

The service used locum and bank staff to lessen risks of staff shortages. Prior to our site visit we had received comments from staff that requests for bank staff were often unfilled because of a complicated request process that involved multiple levels of authorisation. At the time of our site visit, the process for requesting bank staff had been simplified and staff reported requests for bank shifts were more frequently being filled. At the time of our site visit, there were no vacancies in the nurse work force in the medical care services. Agency nursing staff were not used, and bank staff were used to fill vacant shifts due to sickness or to fill shifts that were required to provide one to one observation and care for patients who required it. There was an orientation process followed when staff were moved to different wards in order to support patient safety.

In the 3 months prior to our site visit across the medical and older persons medical care groups, the use of medical locum staff was 9.7% of the workforce, use of nurse bank staff was 16.7% of the workforce and healthcare support worker bank staff were 27.3% of the workforce. There was no use of agency nurses or healthcare support workers.

We did not receive any concerns from patients or staff about access to medical staff. However, because there was a range of medical teams reviewing their patients on the acute medical unit, this meant nursing staff did not always know when patients were planned to be reviewed by medical staff.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff had access to an infection prevention and control policy and supporting guidance. The policy and guidance reflected national guidance such as that from UK Health Security Agency, the National Institute for Clinical Excellence and the Infection Prevention Society.

Most areas were visibly clean and had suitable furnishings which were visibly clean. Cleaning staff were visible in all areas. Observation showed staff washed their hands between patient interactions, cleaned equipment between patients use and wore clothing that ensured they were bare below the elbows. Equipment on the wards had ‘I am clean’ stickers on them, which detailed the date and time they were last cleaned.

Staff had access to personal protective equipment, such as disposable gloves and aprons, as required for the areas they worked in. We observed that staff used personal protective equipment appropriately.

There was an infection prevention and control audit programme that included standard precautions, use of personal protective equipment and hand hygiene. Data provided by the service showed all wards and departments were compliant with hand hygiene process. Use of personal protective equipment audit data provide by the service showed that for 6 of 14 wards assessed in April and March 2025 personal protective practices were not always fully followed by all staff. However, during our site visit we did not observe any concerns with staff use of personal protective equipment.

Infection Prevention and Control audits required a compliance rate of 90% with the infection prevention and control standard precautions. Three of the 14 ward areas assessed were below the 90% target (80% and 85%) in April 2025.

Staff on wards and departments completed a daily cleaning and infection prevention and control list to support consistent adherence to infection control protocols. Staff also completed cleaning audits monthly. The sample of cleaning audits provide by the service showed that most wards and departments met the target of 90% compliance with cleaning. The service followed the NHS England National Standards of Healthcare Cleanliness, cleaning audit score. These national standards reflect modern methods of cleaning and infection prevention and control. They aim to drive improvements in cleanliness by focusing on a collaborative approach in maintaining cleanliness and a required star rating to be displayed giving patients, staff and the public a visual score about the standard of cleanliness. We observed these scores displayed in wards and all achieved the highest score.

The decontamination of reusable medical devices policy gave staff guidance about the decontamination and disinfection of reusable devices. The policy referenced relevant national guidance. Leaders said an “Endoscopy Units – Decontamination Policy” was going through the approval process with an anticipated approval date of June 2025. Observations during the onsite inspection did not identify any concerns with the process staff followed to decontaminate endoscopy equipment.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The medical care services followed the trust’s systems for the safe prescribing, administration, and storage of medicines. Across the observed wards and departments, staff demonstrated compliance with national guidelines including those from the National Institute for Healthcare Excellence (NICE) and used electronic tools to support safe and effective medicines management. Medicines reconciliation practices varied between wards but were generally aligned with Trust policy, with dedicated pharmacists and pharmacy technicians playing key roles in this process. Medicines reconciliation is the process of accurately listing a person’s current medicines. There were staffing pressures within the pharmacy department, affecting timeliness of medicines reconciliation.

All patients’ notes and prescription charts we reviewed were complete with necessary fields completed, such as allergy status. Records demonstrated staff administered patients prescribed medication within the correct time frame.

Staff had access to medication advice and supply of medicines seven days a week. Staff were aware of the avenues for contacting pharmacy to arrange in-patient discharge medication for patients.

On wards, medication was stored safely and in appropriate areas, except for 1 oxygen cylinder on 1 ward. Keys for controlled drugs (CD) cupboards were kept with appropriate members of staff and access was restricted to staff involved with administration of controlled medicines.

Ward staff monitored medicine fridge temperatures. Our review showed that on some wards there were occasions when at a ward level medication fridge temperature were not recorded.

Training and competency checks for staff were comprehensive and consistent across all areas with mechanisms to investigate and report on medication errors and share the learning of such events. There was a clear presence of clinical pharmacists and pharmacy technicians contributing to medicines reconciliation and medication safety. Patient Group Directions (PGDs) were in place to allow for appropriately trained staff to administer medicines within a specific framework.

The service completed audits about medicines storage, fridges, missed doses, critical medicines and bedside cabinets. Trust wide the auditing of medicines management was undergoing review with the aim to streamline the process as the current process was lengthy and time consuming.

Medicines reconciliation was part of the pharmacy improvement work. Trust wide there was a plan to digitalise this as they believed the existing method gave unpredictable results which they did not believe reflected the actual completion of medicines reconciliation on the wards.