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Queen Elizabeth Hospital Requires improvement

This service was previously managed by a different provider - see old profile


Inspection carried out on 7 - 10 March 2017

During a routine inspection

We undertook an announced inspection at the Queen Elizabeth Hospital as part of a planned comprehensive inspection of Lewisham and Greenwich NHS Trust from 7-10 March 2017.

Queen Elizabeth Hospital (QEH) is part of Lewisham and Greenwich NHS Trust. The trust was formed in October 2013 by the merger of Lewisham Healthcare Trust and the Queen Elizabeth Hospital Greenwich (following the dissolution of the South London Healthcare Trust by the Trust Special Administrator). The trust provides acute and community services for more than 526,000 people living in the boroughs of Lewisham, Greenwich and Bexley.

In February 2014 QEH had a planned inspection using our new comprehensive methodology and was rated overall as requires improvement.

Due to CQC receiving increased number of complaints and concerns being reported by patients, relatives and staff, we undertook a further inspection of the emergency department and medical services at the Queen Elizabeth Hospital in June 2016. We rated both services as requires improvement.

This most recent inspection was carried out to determine whether the hospital had made progress following their 2014 comprehensive inspection and 2016 focussed inspection.

We rated Queen Elizabeth Hospital as requires improvement overall. Initially some progress was made following the inspection in 2014, but since then the trust has found it hard to sustain any further improvements.

We rated safe, effective, caring, responsive and well-led as requires improvement.

Maternity and gynaecology and outpatients and diagnostic imaging services were rated as good.

Five services, urgent and emergency services, medical care, surgery, critical care and services for children and young people were rated as requires improvement and end of life care was rated as inadequate.

Our key findings were as follows:

  • The hospital had systems for reporting incidents, but we found learning from incidents was variable and not fully embedded across all services.

  • Medical and nursing staffing levels were not always in line with national guidance. There was a shortage of consultants on the critical care unit and in services for children and young people.

  • Completion rates for mandatory training for both nursing and medical staff did not always meet the trust standard.

  • In some services we observed non-compliance with infection prevention and control practices, hand hygiene, and the environment some patients were cared in had limited space and potentially compromised their safety.

  • Medical patients who were cared for in surgical wards were not always reviewed by the medical team. Staff described significant difficulties in reaching the medical team responsible for these patients.

  • The majority of the services we inspected were providing effective care. However, surgery was rated requires improvement and end of life care was rated inadequate.

  • The hospital performed worse than the England average in some of the national surgical audits.

  • The uptake of appraisals was variable and in surgery the uptake was low.

  • We found many good examples of multidisciplinary working, but there were also poor interactions between some teams.

  • The majority of the services we inspected carried out audits, but in end of life care we found limited audit activity or benchmarking to assess the effectiveness of the service. The end of life care pathway was also inconsistently applied.

  • In the majority of services we inspected we found staff were caring and compassionate. However, in medicine and end of life care we found that staff did not always demonstrate a caring approach to patients and did not always maintain patients’ privacy and dignity. Feedback from patients in these services was variable.

  • Patients described staff as ‘friendly’, ‘helpful’ and ‘attentive’, but patients on some medical wards described staff as ‘rude’ and ‘abrupt’ and said they experienced long waits for staff to respond to their call bells.

  • In the majority of services patients were involved in discussions about their care and treatment. In medical care some patients told us they were not always provided with information or told why for example their medicines had been changed.

  • Patients were not always treated in a timely manner and within national access standards.

  • Some patients experienced long waits in the emergency department, had their surgery cancelled and were delayed in being discharged from critical care due to a lack of available beds.

  • The hospital had a high ‘did not attend’ (DNA) rate for outpatient appointments, higher than the England average.It was also not meeting the operational standard of 93% for people being seen within two weeks of an urgent GP referral for suspected cancer.

  • There were not always sufficient staff to meet the individual needs of patients, for example those requiring one to one support.

  • Mixed sex breaches sometimes occurred in critical care and surgery and the location of the gynaecology clinics and early pregnancy unit was not sensitive to the needs of some women.

  • Complaints were not always responded to within the agreed timescales. Additionally, oversight of agreed actions resulting from complaint investigations was limited.

  • All of the services we inspected had systems to monitor the quality and safety of the care they provided, but we found they were not always effective or proactive.In some services there was low attendance at some of the meetings, sometimes due to insufficient staff.

  • Services had risk registers, but not all of the risks identified during the inspection were recorded on the registers and some risks, critical care and services for children and young people, had been on the register for up to three years without any action being taken. We also found a lack of ownership of the registers in some services with no evidence that risks were regularly reviewed.

  • Some staff did not feel involved in discussions or plans for their service and we received variable feedback on how well the hospital engaged with staff, the working culture and morale.

  • Cross site working was happening to different degrees in each service, but was still at a relatively early stage.


  • Many staff we spoke with had attended safeguarding training for children and adults and knew the action to take if they suspected abuse.

  • Emergency equipment, including resuscitation trolleys, were maintained and we saw evidence of regular safety checks.

  • We also found care and treatment was informed by evidence based guidance and staff could access guidelines via the intranet. .

  • Nutritional risk and screening tools were used to assess and monitor patients’ nutritional needs. Nursing staff had worked with the catering team to provide more flexible mealtime options for patients with dementia or reduced appetites. In maternity mothers received one to one and group support with breast feeding.

  • Staff had a good understanding of consent process and recognised when the best interests of the patients had to be considered.Staff obtained consent from children and young people and parents involving both the child and the person with parental responsibility in obtaining consent where appropriate.

  • Maternity service had a range of expertise and specialist support available for all women.

  • Some progress had been made in meeting the needs of patients living with dementia including increased activities, improvements to the environment and the introduction of a team volunteers who were being trained in working with people with dementia, which included providing enhanced care.

  • Translation services were available and a multi-faith spiritual team was available to provide support within the hospital.

  • Staff were positive about the local managers and felt they were approachable and supportive.

  • Staff told us there was an open culture and they felt able to report concerns.

We saw several areas of outstanding practice including:

  • The uniquely designed door handles that had been installed on the doors to the neonatal and oncology units demonstrated the service was focused on reducing the risk of infections.

  • Tiger ward had provided additional support to families and patients by introducing an informal coffee morning open to all patients on their case load and not just receiving treatment.

  • The speech and language therapy manager had implemented a risk feeding protocol following a successful research pilot project. This resulted in demonstrable outcomes for patients, including a 10% reduction in the admission of patients with dysphagia through more effective feeding regimes. As part of the project new guidance was issued for patients and staff and a risk feeding register was implemented to help the multidisciplinary team track patients cared for under the new protocol.

  • Staff in the Trafalgar Clinic provided care and treatment for patients in a nearby prison. Each patient’s records were maintained on the service’s electronic patient record system. This meant when a patient left the prison service, there was no disruption in care or treatment because clinical staff always had access to this. In addition, if the patient moved out of the area, the electronic records could easily be shared with pharmacists and health workers in the offender resettlement programme. This meant patients received continual care and were at reduced risk of developing health problems associated with an interruption to antiretroviral therapy.

  • In the two years prior to our inspection, sexual health and HIV services recruited up to 50% of the participants for the trust’s whole clinical trial and research portfolio. This resulted from a policy of proactive and early-adoption participation that was part of a two-year strategy to improve participation in research in other hospital departments and services.

  • In critical care there was a dynamic programme of research and development enabled by the full time appointment of a research nurse working with doctors including consultants. Examples of research studies completed in the past year included a study exploring the relationship between family satisfaction and patient length of stay, and a pilot study looking at the improved physiotherapy outcome measure by the use of cycle ergometry in critical care patients. The trust recognised only a small sample size was used for each study.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Review and improve the systems for monitoring and improving the quality and safety of care including attendance at key meetings in ED, surgery, critical care, services for children and young people and end of life care.

  • It must ensure all risks are included on the risk register and are regularly reviewed and updated and carry out audits to monitor the effectiveness of treatment and care. ED, surgery, critical care, services for children and young people and end of life care.

  • Ensure all risk assessments are carried out on patients in critical care.

  • Ensure medical and nursing staffing levels are in line with national standards in services for children and young people, ED and end of life care, to provide safe continuity of care for patients.

  • In surgery, ensure that patients are cared for in areas that are appropriate to their needs and have sufficient space to accommodate all equipment and does not compromise their safety and staff have the relevant skills and knowledge to care for them.

  • The children’s service should review the consultant cover provision to ensure it meets national standards and provide more continuity for patients in the neonatal unit.

  • Ensure patients requiring end of life care receive appropriate and timely care.

In addition the hospital should:

  • Work to share and embed learning from incidents in all services and across sites.

  • Ensure staff comply with infection prevention and control policies and procedures.

  • Ensure the ED has a separate room for the storage of medicines and medicines are stored safely in all areas.

  • Ensure staff working on medical wards and in end of life care have the values and attitude necessary to treat patients, their relatives and visitors with dignity and respect. This includes staff treating them in a caring and compassionate way at all times.

  • Ensure medical patients are appropriately reviewed when they are cared for on other wards and that all staff know who is responsible for them and they are contactable.

  • Ensure that in surgery patient records are stored and held securely in one document.

  • Ensure all patient records are complete and accurate including risk assessments.

  • Ensure all patients have their pain assessed and receive analgesia in a timely manner

  • Improve compliance with mandatory training completion rates for modules that are below the trust target in all staff groups.

  • In critical care consider ways to introduce multidisciplinary meetings and ward rounds to review care and treatment of patients.

  • Ensure there are ongoing arrangements for measuring and reporting patient satisfaction in critical care.

  • Review the arrangements for bereavement services.

  • In critical care, ensure formal arrangements for emotional and psychological support of patients and families including access to clinical psychologists are in place.

  • Review and update the operational policy for the critical care outreach team and ensure sufficient staff are deployed every day to provide an effective service.

  • Review the environment and waiting times for women using the gynaecology service.

  • Develop outcomes for gynaecology.

  • Ensure staff working in HIV, GUM and sexual health services are informed and involved in any future plans for the service.

  • Review the provision of care on Hippo Ward to ensure it is adequately staffed and is open long enough to support patient flow.

  • Review the level of cover currently provided by play specialists to make sure that children are supported appropriately.

  • In services for children and young people, encourage attendance at quality and safety board meetings so that information can be shared and discussed effectively.

  • Complete two year follow ups of babies admitted to the neonatal unit as part of the national audit.

  • Ensure patients who are at the end of their life, and their relatives, are ensured privacy.

  • Improve cross site working in all services.

  • Work to reduce the number of cancelled operations and improve referral to treatment times and reduce the ‘did not attend’ (DNA) rate for outpatient appointments.

  • Continue to recruit to medical and nursing vacancies in outpatients and diagnostic imaging

  • Respond to complaints within agreed timescales.

  • Improve communication and working relationships between different staff groups.

  • Provide sufficient staff to care for patients who need one to one care.

  • Identify ways to empower and support staff to make improvements and take the lead in decisions and improvements in their services.

Professor Edward Baker


hief Inspector of Hospitals

Inspection carried out on 7, 8 and 18 June 2016

During an inspection to make sure that the improvements required had been made

We undertook an unannounced inspection at the Queen Elizabeth Hospital because of concerns raised by patients and the high number of safeguarding incidents at the hospital including the Emergency Department and the medical wards.  

In February 2014, we completed a comprehensive inspection of the trust which was rated as Requires Improvement overall.  At Queen Elizabeth Hospital Medical Care was rated as Requires Improvement and the ED was rated as Inadequate.

We inspected on 7, 8 and 18 June 2016.

We visited the ED and the hospital’s medical wards including care of the elderly. The inspection was responsive and unannounced based on concerns we had about the care patients were receiving at the hospital.

Our key findings were as follows:

  • The Emergency Department (ED) had made some progress since the last inspection, in 2014, including an improved pathway for all ED

    patients to the urgent care centre (UCC),opening a clinical decision unit and a Frailty Assessment Unit (six days prior to our visit on 18 June 2016).

     However, on the 7 and 8 June we found problems similar to those during the previous inspection in 2014; rapid assessment and treatment suspended to accommodate patients who were waiting for beds, patients being cared for in chairs (and in public corridors during this inspection), and long waiting times in the ED due to an increase in demand and a lack of available beds in the hospital.

  • The trust had introduced other initiatives to help improve patient flow including a discharge lounge but, on the first two days of the inspection we found the discharge lounge was being used as an escalation area and was unable to meet the needs of some of the patients admitted there
  • Patients’ vital signs were not always monitored, or action taken, in line with the trust’s policy and national guidelines.
  • Delays in responding to referrals by speciality teams outside of the ED  was impacting on waiting times for patients.
  • Staff in the ED provided compassionate care and patients spoke positively about the staff. 
  • Risks, in relation to capacity identified during the inspection were included on the risk register.   
  • Staff were working in a difficult and challenging environment but, were positive about the support they received from their immediate line managers, but were less positive about the executive team
  • In medical care patient safety was compromised through incomplete, inaccurate and contradictory recording in patient's notes and variable compliance with infection prevention and control procedures, including good hygiene practice, and medicines management.
  • Although, we saw many staff being kind and caring towards patients on the medical wards, we also observed some speaking inappropriately to patients demonstrating a lack of sensitivity and compassion. They either did not have enough time to help patients with their personal needs or did not see it as part of their role.
  • We found problems with delayed discharges, over 50% of patients had a delayed discharge, and patients had extended stays on the acute medical unit which were also found during the previous inspection. 
  • There were limited resources and support for staff to meet the individual needs of patients, for example those living with dementia or patients for whom English was not their first language.
  • Governance and risk management processes were not effective and senior nurses in medical care  were unaware of the key risks for their areas.
  • We found a significant variation in the leadership of the medical wards and although quality monitoring was taking place we found a number of problems which should have been identified through the quality monitoring process. Staff gave differing responses about support from their managers and in some areas felt there was a lack of oversight.  

During our inspection, we did not observe any areas of outstanding practice.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure patients are cared for in areas that are appropriate, meet all of their needs and have sufficient space to accommodate the potential number of people using the service at any one time.
  • Ensure assessments of patients and observations are recorded and action is taken, where appropriate, in line with hospital policy.

  • Do all that is reasonably practicable to mitigate any risks related to delays in patients being seen and assessed and treated in the ED and transferred to an appropriate ward/clinical area for on-going treatment.

  • Ensure patients on medical wards have appropriate risk assessments fully completed that meet their needs. This includes where patients have a Protected Characteristic under the Equality Act.

  • Have effective systems and processes to assess and monitor the quality and safety of care and treatment in the ED and medical care.
  • In medical care, all medicines must be stored safely, securely and in a temperature-controlled environment in all areas. This must include documented daily temperature checks and a documented stock control system.

  • Ensure patient records, including prescribing records, contain all relevant information.

In addition the trust should: 

  • Develop a formal induction for agency nurses in the ED 
  • Ensure staff comply with infection prevention and control policies and procedures.
  • Should have better oversight of cleaning and hygiene standards on ward 18. This should include bedside equipment, equipment storage rooms and food preparation areas

  • Ensure staff training in medical care meets the needs of those working in clinical areas. This should include input from staff that indicates the level of training they have received is sufficient to carry out their responsibilities safely.

  • Ensure staff, in medical care, receive up to date life support training at a level appropriate to their role and responsibilities

  • Continue to work to reduce the number of delayed discharges
  • Ensure staff fully understand the role of the dementia lead nurse and how to access services available to patients.

  • Ensure staff working on medical wards have the values and attitude necessary to treat patients, their relatives and visitors with dignity and respect. This includes staff treating them in a caring and compassionate way at all times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 26 - 28 February 2014

During a routine inspection

During the inspection, the team looked at many areas. The detail of their findings is within the main body of the report. However in summary we found that:

On both sites, elements of the acute medical pathway (which is based on a different model on each site) are not providing optimal flow of patients through the hospital. This includes difficulties in accessing critical elements of some patient pathways provided externally to the Trust.

On the Queen Elizabeth site the A&E environment is not considered by the inspecting team to be fit for purpose.

On the Queen Elizabeth site, following admission via A&E, delays in access to investigation were witnessed, and also delays in accessing specialist internal opinion and by external transfer to specialist units.

The approach taken by the executive team to the formation of a single inclusive organisation, is appreciated by staff on both sites. Despite acknowledgement and appreciation of the executive teams approach to the formation of a single, inclusive organisation on the Queen Elizabeth site, staff at the focus groups on that site remained concerned in view of their recent experiences.

The review team felt that the Executive Team should plan to re-evaluate their management capacity to address the issues described at regular intervals to ensure that this remains adequate.

We did however also see areas of good practice. These included

The single governance structure, including increased clinical involvement and the appointment of senior clinicians from the Queen Elizabeth (Greenwich) site to 4 Divisional Director roles, is also appreciated by staff on both sites.

The staff on both sites are committed to high quality care and this is a focus of their work.