Queen Elizabeth 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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also ensured that people’s liberty was protected when it was in their best interests and in line with legislation.

At our last assessment, we rated this key question as good. This key question has remained the same and has been rated good. This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service did not always have a proactive and positive culture of reporting safety events and investigations of incidents. Lessons were not always learnt to continually identify and embed good practice.

During the assessment, some staff were unclear about escalation pathways and lacked confidence in challenging unsafe practice, limiting learning and sustained improvement. Leaders acknowledged this longstanding issue and were reviewing it at senior trust level. However, other staff said they could escalate and share immediate incidents, were familiar with the electronic reporting system, and understood how reports progressed through health and safety and clinical governance teams, with outcomes shared with managers, patients, and staff. Staff also understood the duty of candour and said they were open with patients and families when things went wrong. Staff described receiving informal debriefs and emotional support from colleagues after incidents, and the practice development matron supported staff to reflect and update competencies.

In the last 6 months, there had been 36 incidents, with 6 closed, while 34 remained open and 2 were unassigned. The Trust’s policy requires incident investigations to be completed within four weeks unless exceptional circumstances are documented, but most were overdue. This meant investigations were not progressing within required timeframes, reducing assurance that learning cycles were completed or that improvement actions were being driven promptly. Staff said feedback often took longer than expected, and incidents were discussed only during infrequent safety huddles, limiting timely reflection and action.

Some organisational systems also affected how well learning could be embedded. The main OPD booking office managed most new routine and urgent appointments, providing a centralised structure for scheduling. Clear booking rules were set through standard operating procedures (SOPs), including standardised clinic templates and escalation processes for urgent requests. Did-Not-Attend (DNA) processes were defined, with first‑appointment DNAs automatically rebooked, second consecutive DNAs discharged to GPs, and subsequent DNAs requiring clinical review. However, our review of documentation demonstrated that the service did not always identify themes and patterns of how well DNA patterns or booking‑system themes were fed back into learning discussions, which limited understanding of system‑level issues such as communication gaps or avoidable delays.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services

The referral and admission processes in place enabled staff to receive the information needed so they could safely meet people’s needs. Staff reviewed clinic lists, room requirements and equipment before each session, and we saw routine checks of clinical rooms, emergency equipment and storage areas. These checks helped staff prepare safely and supported informed decision‑making.

The service had a centralised booking office, which coordinated most routine and urgent outpatient appointments. Appropriate systems were in place to ensure essential information was received at the start of the patient journey, helping staff allocate the correct clinic, room and equipment for each appointment. Clear booking rules and standardised clinic templates, set out in the OPD’s SOP, supported consistent and safe scheduling across services. Processes for urgent requests, room prioritisation and standardised systems to help reduce variation and ensured patients were booked into clinically appropriate slots. The booking office worked closely with OPD teams to manage room conflicts, cross‑site capacity, and last‑minute changes, contributing to safer flow and reducing the risk of patients being placed in unsuitable clinics.

The service had clear emergency‑escalation pathways, requiring staff to make immediate external referrals to 999 or the Emergency Department and document all advice and urgency in the clinical record. Processes also existed for maintaining pathway continuity through a clinic cancellation escalation SOP, with cancellations monitored by the performance and information team, reviewed monthly, and escalated where repeated or late, to minimise disruption and ensure clinics were delivered safely and consistently.

The service worked effectively across specialties to maintain safe pathways during OPD visits. Staff directed people between consultation rooms and phlebotomy to ensure no one waited without information or oversight. Different clinic types, such as dermatology minor procedures and phlebotomy, had clearly defined requirements, and staff ensured the right room, equipment and support were available. Focus‑group discussions showed that daily huddles were used to identify risks, adjust staffing and confirm pathway changes so patients moved safely between stages of their care.

Gynaecology OPD staff described strong networks across south east London. They said hysteroscopy training, once only available in another region, was now offered locally, strengthening joint working with community gynaecology teams, General Practitioners (GPs) and the south east London Cancer Alliance. Staff acknowledged there was more progress to make but noted that foundations for safer and more consistent pathways were actively being developed.

Continuity after appointments was also supported. Aftercare information following blood tests clearly set out expected symptoms, signs of complications, when to rest, when to seek help, and how results would be communicated, helping people understand next steps and when to escalate concerns at home.

Staff involved appropriate healthcare teams, such as specialist nurses, practice educators and clinical leads, when patients required additional support. They said ongoing digital improvements to booking and scheduling aimed to improve patient flow and reduce variation across the OPD. Staff also reported that the trust was developing plans to strengthen the Referral to treatment (RTT) pathway as part of a wider elective‑improvement programme. Proposals included enhancing specialist advice, improving Referral Assessment Services (RAS) triage to support and refine complex care pathways in line with Getting It Right First Time (GIRFT) reassessments. These changes aimed to reduce waiting times from summer 2026 and improve the consistency and safety of elective care pathways.

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 appropriately, although some staff did not always feel confident escalating safeguarding concerns.

The safeguarding training compliance across the OPD. Nursing, systems and rescheduling teams all achieved 100% compliance. Admin team achieved 94.8% and Macmillan Brook OPD achieved 88.9%, below trust target of 90%. Safeguarding Children and Young People training followed the same pattern, with most teams again reaching 100% compliance. Staff were mapped to Level 3 safeguarding requirements and monitored monthly. This showed strong organisational oversight, although high training compliance did not always translate into confident safeguarding practice.

Safeguarding posters were displayed in staff rooms and included clear contact numbers for the safeguarding team, helping staff know how to escalate concerns. Staff told us they could contact safeguarding leads easily and seek advice at any time. Safeguarding leads were accessible and staff knew where to find safeguarding resources.

Staff were also aware of their responsibilities for safeguarding children attending the department. Although the OPD department at this site does not attend to children under 10 years old, staff had access to child safeguarding referral pathways and were required to follow the same escalation processes as staff in emergency or inpatient services. Staff understood the need to consider risks to children when adults attended the service, including situations involving domestic abuse, parental mental health needs or substance misuse. The trust had a child and infant abduction policy that applied to OPD, outlining staff actions, escalation routes and security procedures in the event of a suspected abduction. However, while staff had access to safeguarding pathways for children over 10 years old attending the department, we did not always find consistent evidence that some OPD staff were familiar with or could describe the specific child‑abduction procedures, as required by the trust’s policy.

Furthermore, staff had guidance on restraint and restrictive practice for situations where a person lacked capacity and was at immediate risk. The Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) policy explained that any restraint must be the least restrictive option, time-limited and clearly documented. While restraint is uncommon in OPD, this guidance helped staff understand how to respond safely to complex situations.

However, some staff we spoke with in OPD did not always feel confident identifying or escalating safeguarding concerns, despite high levels of safeguarding training. Several staff were unable to clearly describe what should be considered a safeguarding issue, what should happen after they raised a concern, or how to apply requirements such as the MCA or DoLS. Interview evidence showed that adult safeguarding and Mental Capacity Act (MCA) decision‑making remained challenging for some staff, creating a risk that concerns could be missed. The Trust was aware of these gaps, and the safeguarding team had taken action by providing bespoke face‑to‑face training, micro‑teaching, improved MCA templates and targeted support to strengthen staff understanding. Safeguarding records and Trust‑wide data showed that concerns were being raised and referred when thresholds were met, and safeguarding advisors remained accessible for advice. Despite variation in confidence, staff knew how to escalate concerns, policies were current, training compliance remained high across the organisation, and there was information displayed in the department providing signposting and support for people experiencing domestic violence.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff helped patients understand their care and manage risks. Procedures were explained clearly, and staff adapted communication for people with additional needs, including providing written information or checking understanding. When communication fell short, complaints showed that managers reviewed concerns and reinforced expectations with staff.

Patients were encouraged to give feedback, supported by a dedicated “Give Feedback” page on the trust website and posters in the department. Staff also received verbal feedback in clinics. Complaints were investigated and responded to, and completed investigations showed that learning was shared and practice followed up, demonstrating that the service acted on issues raised.

Staff supported people to make informed decisions, including those making advance refusals of treatment. Staff generally communicated well with patients, checking they understood their care and treatment and providing clear information during procedures. We saw aftercare guidance that explained symptoms, risks and when to seek help, supporting people to keep themselves safe at home. Consent and mental capacity policies were accessible, and staff escalated complex decisions to senior colleagues. They also recognised when advocacy would be helpful and complaints documentation showed some patients used independent advocates, and the trust responded promptly to their enquiries.

Staff knew what to do if a patient became unwell during an appointment. They described confidence in escalating concerns and seeking help to manage deterioration. All nursing staff were compliant with adult and paediatric basic life support training, helping ensure emergencies were managed safely. The World Health Organisation Surgical Safety Checklist was used in dermatology minor procedure clinics, supporting safer practice through consistent checks and communication before procedures.

The service did not always detect and control potential risks in the care environment to deliver safe care.

The suitability of the OPD environment varied, and several issues increased risks to privacy, dignity and patient flow. We observed staff smart cards left in computer terminals and electronic patient records open in public areas, meaning confidential information could have been accessed by others. Senior staff were notified at the time and took immediate action to reduce this risk.

Clutter in some clinical rooms, stock stored in corridors and blocked spaces also made some areas harder to clean and increased the risk of falls. Environmental audits showed inconsistent cleanliness and equipment checks. Phlebotomy scored 91.45% overall, with some rooms scoring between 83.3% and 86.7%, where dust, limescale, stained surfaces, unclean dispensers and cluttered low‑level areas were found. Area C scored 96.48%, with consultation and waiting rooms scoring 90% to 100%, though several toilets scored 92.9% due to dusty vents, limescale and waste‑bin contamination. In contrast, the Minor Ops Room scored 100%, showing high standards were achievable when routines were consistently followed. These findings showed that important checks were not always completed in the same way across all areas.

Other risks were identified during the assessment. Confusing signage, cluttered check‑in points and repeated booking‑in failures left some patients feeling stressed and unsure of where to go. Some clinic rooms were small, cluttered and difficult to work in, restricting movement and reducing emergency access. We also found that some rooms were used for informal storage. Cleaners’ rooms containing liquids were occasionally unlocked and accessible to the public. Several waiting areas lacked child‑friendly spaces, bariatric seating or baby‑changing facilities, and information displays were not always well‑positioned or kept up to date. Staff also said some equipment, such as suction units and sharps bins, was not consistently stocked or checked.

Despite these concerns, there were strengths in the OPD area. Fire safety arrangements were mostly strong; we reviewed the fire risk assessment for outpatients and found it was completed and in date. Fire doors, extinguishers and signage were in place and staff described their evacuation routes clearly. There were 2 readily available resuscitation trolleys in Areas C/D and E, as well as portable defibrillators, which was correctly stocked and in date. However, resuscitation daily checklists were not available on either resuscitation trolley at the time of inspection. These checklists support routine checks to help ensure that emergency equipment is available, functional, and appropriately stocked.

Most patient‑facing areas and clinic rooms observed on the day were clean, well maintained and suitable for consultation and colour‑coded zoning of the OPD supported navigation. Many rooms scored highly in audits, and the minor operations room had consistently achieved 100% in cleaning checks. Most equipment's was in good condition, stored safely and PAT‑tested, showing it had been checked for electrical safety. Emergency call bells were fitted in clinical rooms, and staff told us they could use them to summon help if a patient collapsed or if they felt unsafe. Although CCTVs were not seen in the OPD areas, safety call buttons were also available, which supported staff to call for assistance quickly if an incident occurred, and phlebotomy rooms were equipped with panic alarms to support staff safety. Staff said they escalated environmental issues, including cleaning concerns or broken equipment, and that estates teams usually responded quickly.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Most staff told us that leaders were visible, supportive and responsive to staffing pressures. Medical cover was adequate throughout the day, escalation routes for deteriorating patients were clear, and medical colleagues responded promptly to urgent queries. Staff also described strong teamwork, which helped clinics run safely even when activity increased or staff needed to be moved between areas.

Although, staffing pressures continued to affect the OPD service, with sickness absence at 15.12% and a turnover rate of 12.98%, compared with a twelve‑month average of 19.27%. The service had 144.46 WTE staff in post against a twelve‑month average of 141.84 WTE, with 13.40 WTE vacancies amounting to a 9.25% vacancy rate, and staff said this often resulted in colleagues being moved between clinics at short notice or starting shifts earlier than their contracted hours. However, staffing levels in OPD were generally safe. Rotas were reviewed daily to check the needs of each clinic, and staffing was adjusted to ensure shifts were safe. Staff said this process helped them maintain safe care even during periods of sickness or unexpected absence.

Mandatory training performance across nursing and allied health teams was strong, with 100% compliance across all required modules. Data provided by the trust showed they had exceeded NHS England’s target for completion of each tier of Oliver McGowan training. The only exception was the Macmillan OPD team with Oliver McGowan Tier 2 compliance of 55.56%. The administrative team compliance of 71.46% was below the trust’s 75% target for this module. Senior staff had actions in place to improve these figures through targeted sessions and additional reminders. Staff said training was relevant to their roles, and new starters received trust‑wide and local induction, followed by buddying and supervision to build confidence.

Appraisal compliance was strong at 93.5%, above the trust target of 90%, showing effective oversight of staff development. Staff explained that high turnover was partly due to Band 2 staff being deliberately upskilled to Band 3 roles, after which they often moved to other directorates for career progression. Senior leaders ensured temporary staff received local induction and were familiar with the area before supporting clinics, and staff told us they felt confident escalating staffing concerns and that managers responded quickly to maintain safe cover.

The service did not always assess and manage the risk of infection well. Staff did not always adhere to infection‑control principles including effective hand hygiene. However, where processes were working, staff maintained equipment safely, kept areas clean and well‑maintained.

The audit data in the January 2026 decontamination standards audit for the main OPD area scored 83%, ranking 63 out of 76 areas trust wide. The highest scoring areas achieved 100% for hand hygiene, correct PPE use and use of appropriate cleaning products. However, Staff were not always observed to be following safe infection control (IPC). We observed poor hand hygiene, with some staff not consistently washing hands or using gel before and after patient contact. Some staff wore jewellery and were not bare below the elbow, and we saw medical staff wearing gloves and not changing them between patients, which increased the risk of cross-contamination. These lapses showed that IPC standards were not applied reliably in all areas of the department.

Despite these concerns, clinical areas were visibly clean and well-maintained. Rooms, waiting areas and treatment spaces were tidy, and furnishings were in good condition. Cleaning records were up to date and showed that rooms were cleaned regularly throughout the day. Most curtains in observation rooms were also clean and displayed appropriate labelling.

Equipment was kept clean, with ‘clean’ stickers visible and in date. Staff described following appropriate processes to prepare rooms and equipment between clinics and at the start of shifts, and we saw that most items were ready for use. Personal Protective Equipment (PPE) was available, and staff used gloves and aprons during procedures, although not always in line with best practice. Hand‑gel stations were accessible throughout the department, and staff told us that monthly IPC audits took place in some specialities, supported by an IPC link nurse who was currently on leave.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff followed good practice in the storage, administration and recording of medicines where systems were embedded, in line with recognised national guidance.

Staff followed safe and appropriate medicines management processes. Medicines were stored securely in a locked fridge, and daily temperature checks were completed to ensure safe storage conditions. Staff used approved cleaning products and followed national guidance for preparing, handling and disposing of medicines. These checks were overseen by senior staff who monitored compliance and ensured temperatures were escalated if they fell outside expected limits.

Prescriptions were written or generated electronically and sent directly to the hospital pharmacy, so medicines were available when patients arrived for their appointments. Staff kept accurate records, checked expiry dates, and ensured stock was rotated and ready for use. Medicines used during procedures were documented in the patient record, and any items requiring disposal were managed through the correct clinical waste routes. Overall, systems for storage, transport, prescribing and disposal were well managed and supported safe patient care.