Queen Alexandra Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last assessment we rated effective as good. At this assessment the rating has remained good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

This service scored 58 (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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing, and communication needs with them.

Staff followed care pathways based on national guidelines in order to provide appropriate care and treatment to patients. Staff understood how to access clinical pathways and guidance when needed. Senior managers told us they participated in local and national clinical audits and findings were reviewed and shared.

Staff followed up-to-date policies to plan and deliver high quality care according to best practice and national guidance. Staff had access to policies and treatment guidelines, stored electronically. Policies and procedures were based on best practice from the National Institute for Health and Care Excellence (NICE) and Royal College of Emergency Medicine guidelines (RCEM). These were regularly reviewed and updated both centrally and at trust level.

Guidelines and protocols were available to staff to follow for the most common symptoms patients would attend the emergency department for. These were noted to be in date.

There were recognised pain management systems suitable for both adults and children. Staff used a range of pain scoring models to adapt to individual patient needs. These included the FLACC Scale (Face, Legs, Activity, Cry, Consolability) in infants and non-verbal patients, Pain passports, and Visual grimace scoring. Pain scores were documented at triage and routinely reassessed. The service had relaunched a ‘pain passport’ within PED in May 2025. This tool would be used to help children cope with pain and distress during medical treatment. The document that allowed patients to record their pain levels, coping strategies and preferences for pain management. This was hoped to allow medical staff to better understand and address the child's pain leading to more effective care.

Patients presenting with moderate to severe pain should be assessed promptly and received appropriate analgesia within 15 minutes of arrival, in line with national standards. Nursing staff were able to dispense analgesia under Patient Group Directives (PGDs), and we spoke with patients in the Adult and Child waiting areas who confirmed they had been offered pain relief but were unsure if this was within 15 minutes of arrival. Staff recognised that giving treatments in AUC could be challenging when it was overcrowded and this had affected the ability to give analgesia to patients in significant pain. The AUC working group were reviewing ways to improve the timeliness and quality of analgesia administration in AUC. The trust worked alongside a specialist NHS trust to provide support to people with mental health needs in the emergency department. This enabled staff to protect the rights of patients subject to the Mental Health Act and followed the Code of Practice. At handover meetings, staff routinely referred to the psychological and emotional needs of patients, their relatives, and carers.

However, leaders did not always check to make sure staff followed guidance. For example, there were no auditing of essential guidance such as NEWS2 or deteriorating paediatric patient guidance. There was also poor practice in nursing documentation which had not been identified prior to our assessment.

We also heard how specialist teams to support patients with a learning disability were unable to access essential systems to identify patients within UEC that may have benefitted from early therapeutic input and onward referral.

We scored the service as 3. The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff assessed and met patients’ needs for food and drink and for specialist nutrition. Patients said their nutrition and hydration needs had been met during the course of their wait in the emergency department, regardless of the area they were boarded or waited. Patients and their relatives who were waiting for treatment in the waiting area had access to jugs of water and a selection of snack items. There was a hot drinks service that moved through the department to supply hot drinks to all areas.

Staff told us they followed care pathways based on national guidelines in order to provide appropriate care and treatment to patients. They knew how to access clinical pathways and guidance when needed. Senior managers told us they participated in local and national clinical audits and findings were reviewed and shared.

Staff had access to policies and treatment guidelines, stored electronically. Policies and procedures were based on best practice from the National Institute for Health and Care Excellence (NICE) and Royal College of Emergency Medicine guidelines (RCEM). These were regularly reviewed and updated. Staff protected the rights of patients subject to the Mental Health Act and followed the Code of Practice. The trust had an agreement in place with the neighbouring mental health trust to provide psychiatric and mental health support to patients in the emergency department. This enabled staff to protect the rights of patients subject to the Mental Health Act and followed the Code of Practice. At handover meetings, staff routinely referred to the psychological and emotional needs of patients, their relatives, and carers.

Managers ensured that staff had access to regular team meetings. These meetings were minuted and stored electronically so they could be accessed if staff were unable to attend. Staff also received essential safety and practice based updates electronically and were able to acknowledge they had reviewed these.

Managers provided new staff with appropriate induction and all staff within the trust, regardless of department, undertook emergency department familiarisation.

Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. Staff had annual appraisals with managers. Staff appraisals serve as a structured process to review individual performance, identify development needs, and align personal goals with organisational objectives. They are a key component of staff development, contributing to improved patient care and the overall effectiveness of the NHS. We reviewed data regarding appraisal and saw that 70% of UEC staff had received an appraisal, this was below the trust target of 85%. The lowest uptake in appraisals was in advanced clinical practitioners (ACPs), of who 28% had received one. Advanced clinical practitioners (ACPs) are healthcare professionals, educated to master’s level or equivalent, with the skills and knowledge to allow them to expand their scope of practice to better meet the needs of the people they care for.

There was a weekly teaching session for the resident doctors and a separate teaching session for middle grades. In addition to this, all advanced care practitioner had a 1/2 day of teaching monthly. This meant medical and specialised healthcare professionals were supported to remain up to date with best practice.

However, there was little provision for adult patients with a learning disability in the adult emergency department. We spoke with specialist staff who advised that there were unable to access patient care information for patients in the Urgent and Emergency care department. This was because they did not have access to the patient system that the department utilised. The trust advised that there were resources to support patients with LD. However, no staff we spoke with were able to locate this or determine its location. The high demand for patient areas also meant there were limited areas that could be utilised if a patient became overwhelmed while awaiting treatment.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

The number of emergency admissions waiting more than 12 hours from decision to admit to admission at the trust between February 2024 and January 2025 was 880, more than 4 times as many as February 2023 and January 2024. This was despite there being fewer overall emergency admissions via A&E in 2024/25 compared to the previous year. Staff told us that when it was decided a patient had a decision to admit (DTA), admission to the appropriate ward or clinical area was often not possible as the ward was full.

Patients had to wait either in the emergency department or in an escalation space in the corridor. During our assessment we saw patients waiting in excess of 12 hours with a DTA. On day 2 of our assessment there were over 14 patients who had waited more than 15 hours in the emergency department following a DTA. The patient who had waited the longest had been waiting over 22 hours, despite having a DTA within 1 hour of arriving.

The trust had interprofessional standards in place to outline standards and behaviours that underpinned staff expectations, but these were not always upheld in practice. Delays were often experienced for patients who were referred to some specialties and required a speciality review. The medical team worked to see patient who had waited in the emergency department for a long period of time as part of regular ward rounds. Staff told us that this was not consistent amongst all specialities, particularly surgical, which led to surgical patients experiencing delays of specialist care and treatment.

We also heard how the medical same day emergency care department often contained patients overnight awaiting admission, which meant it could not function to support flow from the main emergency department. Patients being held overnight were also observed in the Emergency Care Centre (ECC), this was not the intention of this area. This meant that redirection of patients from the main emergency department could not occur as there was no space for them to be reviewed and assessed. During our assessment we saw that patients were held overnight in this area on all 3 dates. We heard from staff that the ECC often was unable to take patients before 11am due to bedded patients from the previous night. Minutes we reviewed from safety meetings also highlighted this as an ongoing concern.

Some patients experienced delays as wards would not admit them until diagnostic tests had been completed. For example, any investigations ordered by the speciality team whilst the patient remained in emergency department, remained the responsibility of the emergency department to follow up before they could be admitted into the main hospital. Internal professional standards state the emergency consultant has admission rights if the patient has not been seen within 1 hour however we heard how admitting teams were reluctant to take responsibility for patient admissions resulting in frequent disagreements. This meant some patients experienced delays in admission while hospital teams agreed on the best course of action.

Staff had also raised concerns regarding the admission of patients aged 16 to 17 who were being admitted to adult acute medicine unless they were previously known to the paediatric department. Trust policy stated that the admission to either the acute medical ward or the paediatric ward would be the choice of the patient and their family. However, this was seldom upheld due to resistance from the paediatric ward. This meant there were long delays for these patients in the emergency department, even when beds were available. This translated as a patient being seen in the paediatric department by paediatric emergency doctors but then being admitted to the adult acute medicine ward. We saw incident reporting that had occurred due to this happening. Staff also felt this added to patients in this age range leaving the service before receiving treatment. We reviewed education presentations that had been given to medical staff, including case studies, to improve understanding of this issue among staff to consider how best to admit these groups of patients. This meant there were poor coordination of transitions of care for these patients.

Leaders told us that an admissions criterion was being developed and shared with all trust areas, to identify which ward areas patients held the admission responsibility of a patient dependent on their primary presenting complaint and diagnosis

Furthermore, we heard how the learning disability (LD) team were unable to see if patients they could support were in UEC. This meant they often were only aware of these patients once they had been admitted to the wider hospital. The LD team had put tools and guidance about the support of patients with a learning disability on the trust intranet. However, they were no longer able to access the trust intranet to update this guidance and tools. This presented a risk that staff would not have access to current guidance to enable them to support patients with a learning disability effectively.

Staff held regular and effective multidisciplinary meetings. Doctors, nurses, and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide safe care. Staff held regular and effective multidisciplinary meetings to review patients and improve their care. We saw multidisciplinary working with services, such as frailty teams, patient care coordinators, nursing and medical staff.

Staff shared information about patients at effective handover meetings within the team. These occurred at regularly at designated times to maximise attendance.

Staff were observed as working well together and putting the patients' needs first. There were some established admissions criteria within the main hospital wards such as patients who presented with fractured neck of femur. Additionally, the older persons same day emergency care (OSDEC) would support the main emergency department by actively pulling patients from the emergency department when they anticipated a rapid assessment and discharge.

The frailty team had a static base within the emergency department. We heard how they undertook daily reviews to assess patients who could be cared for in the hospital wards. They aimed to aim to rapidly assess patients with mobility or occupational issues so that they could be discharged. The acute oncology service took acute presentations during the day, including Metastatic spinal cord compressions.

The teams had some effective working relationships, including good handovers, with other relevant teams within the organisation (for example, care co-ordinators, discharge teams, and specialist teams). Staff described a particularly good relationship between the emergency department and the anaesthetic and intensive therapy unit (ITU) teams with 3 of the emergency department consultants being dual accredited ITU consultants.

There was also an emergency pregnancy assessment unit and a surgical same day emergency care service, which were described as working well with direct admissions from the emergency department.

We scored the service as 2. The evidence showed some shortfalls. The service did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Where resources were provided, these were done via digital formats which limited access for some groups of patients. This meant the service did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

Staff supported some patients to live healthier lives by referring patients to services where appropriate. We heard how all patients were Alcohol and Drug screened with referral to relevant support networks if required.

In recent years the trust had undertaken a trust wide smoking ban across the site. Patients were supported with referrals to smoking cessation services. Data provided by the trust showed increasing numbers of patients who were referred to this service ‘quit’ smoking. However, there was no detail to determine how many of these patients were UEC patients or other specialties within the hospital.

Patients were provided with information cards which could be emailed, accessed via QR code, or via a website. These covered areas such as wellbeing & healthier living. There were also digital resources for parents & cares of children and young people alike.

However, we did not see evidence of how patients who may not be digitally literate, may have a learning disability or may not have the means to access digital information could access these resources in a comparable way.

We scored the service as 2. The evidence showed some shortfalls. The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Data we reviewed showed that between February- April 2025, on average 25 patients per day reattended the department within 7 days, this was an improvement on previous performance. However, during December 2024, 7.1% of patients left UEC without being seen compared to 5.4% nationally and 5.1% for the region. In addition to this, some patients awaiting mental health assessment left before their treatment or assessment had been completed. On the first day of our assessment 2 Paediatric patients left before receiving treatment, and 1 left before an assessment could take place after waiting over 10 hours. In the Adult emergency department 21 self-discharged before treatment completion and 13 left before initial assessment (absconded).

Due to the lack of flow into the main hospital, an escalation area was in use in the corridor between resus and majors. This meant that patients could be in the area for long periods, on the first day of our inspection 23 people had been waiting over 15 hours, and 30 people had been waiting over 12 hours. Data provided by the trust showed between 1st February – 30th April, 5926 patients breach the nation 12 hour waiting times. The longest wait in the department in March 2025 was 48 hours and in April 2025 47 hours. The trust’s percentage of patients spending over 12 hours in A&E was consistently higher than the England average from February 2023 to January 2025. In line with this Trust’s estimated number of patients with delay-related harm was almost 2.5 times the England average in January 2025. This had increased considerably since our last inspection.

The service monitored people’s care and treatment to continuously improve it. Staff used recognised tools to improve the detection and response to clinical deterioration in patients as a key element of patient safety and improving patient outcomes. However, it did not monitor compliance with this guidance against best practice.

The department actively contributed to national audits and Quality Improvement Projects (QIPs). The trust participated in the RECM audits for consultant sign off audit, infection prevention and control 20223-23, & Mental Health (Self-Harm) 2022-23. The trust was also actively contributing to the 3 RCEM QIPs at the time of our inspection. These audits were in Time-Critical Medication, Care of Older People, Mental Health: Self-Harm.

Staff used technology to support patients effectively. Hospital systems gave staff access to diagnostic results. The main hospital patient record system held full copies of patient UEC records for staff to refer to.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centered care and treatment.

Staff took all practical steps to enable patients to make their own decisions. All staff we spoke with were able to describe the process of consent according to trust and RCEM guidelines. They explained that this was used for any procedure performed in the emergency department.

Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They supported patients who lacked capacity to make their own decisions or when experiencing mental ill health. Staff understood how and when to assess whether a patient had the capacity to make decisions about their care.

Staff gained consent from patients for their care and treatment during triage in line with legislation and guidance and this was clearly recorded in the patients’ records.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. When patients could not give consent, staff made decisions in their best interest, considering patients’ wishes, culture and traditions. They did this on a decision-specific basis with regard to significant decisions. The service had effective systems to ensure staff assessed the mental capacity of patients and recorded decisions made in a patient’s best interest when applying to deprive the service user of their liberty. Managers monitored the use of Deprivation of Liberty Safeguards and made sure staff knew how to complete them.