Queen Mary's 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

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that staff and leaders delivered care and treatment in line with legislation and evidence-based guidelines. People’s care, support and treatment reflected their needs and any protected equality characteristics, ensuring people were at the centre of their care. We looked for evidence that processes around consent were in line with national guidance. Leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work. Staff worked well together to ensure the best possible care for patients.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people’s outcomes were consistently good, evidence-based guidelines were followed and staff worked well together.

We have not awarded this service a score for Effective.

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

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

People were assessed prior to booking as to their suitability and eligibility for day surgery. Patients undergoing surgery under general anaesthetic had a pre-operative assessment. Team leaders reviewed patient records prior to the day of surgery to identify any additional risks or needs as part of an overall assessment. This included the identification of wellbeing and communication needs. For example, we saw that a patient with a learning disability had their needs assessed and adjustments were made, including enabling them to have their carer with them prior to surgery and in recovery. We saw that 87% of staff had completed training in learning disability and autism awareness and 95% had completed training in dementia awareness, this was above the trust target of 85%. Staff we spoke with demonstrated an understanding of the assessment needs of individuals and options for adjustments to ensure their needs were met.

On arrival to the unit patients were checked in by anaesthetic staff. There were clear assessment processes. This included a review of patients past medical history, medication and physical observations. In addition, as part of discharge planning, staff assessed any additional needs to ensure appropriate arrangements were in place.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. Staff did this in line with legislation and current evidence-based good practice and standards.

Treatment and care were delivered in line with legislation, national guidance and evidence-based practice. Staff had access to trust policies through the intranet system. Staff knew how to access policies and those we reviewed were up to date and based on nationally recognised standards.

We saw that National and Local Safety Standards for Invasive Procedures (NatSSIPs and LocSSIPs) were embedded in practice. We reviewed audit data from December 2024 and saw that safety measures generally demonstrated compliance of between 96% and 100% across surgical specialities within Queen Mary’s Hospital.

Staff followed national guidance on pre-operative fasting. Staff staggered admission times to reduce waiting and minimise fasting times for people. We reviewed preoperative fasting data visible in the department and found that in December 2024 between 50% and 60% of patients fasted up to 4 hours, with 15% to 20% fasting for up to 2 hours. This meant that the majority of patients fasted for longer than national guidelines that state people may drink clear fluids until 2 hours before their operation.

People were discharged post operatively when their condition was stable, and they had managed to eat and drink.

We saw there was a formal annual clinical audit programme to evidence performance monitoring, quality measures or patient outcomes relating to surgical services. There was a corporate audit plan, which included national audits, which the trust was submitting data to.

The service worked well across teams and services to support people. Staff made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

We observed good multidisciplinary working in theatres and recovery. Staff worked well together to support people. Staff told us that medical staff were easily accessible and there were clear arrangements for escalating concerns, including a ‘floating’ anaesthetist should the need arise. Staff met regularly prior to starting theatre lists, to discuss risks and issues and organise themselves.

Staff told us they received support from additional multidisciplinary team members and departments. This included safeguarding, practice education and other specialist services when needed.

Because people accessing day surgery were expected to be discharged following their recovery, it was unusual for people to move between different services. However, in the event of complications where further treatment or care was needed, patients may be transferred to St George’s accident and emergency department. This was always done with a medical escort and relevant patient notes so that the assessment of their needs was shared with the receiving medical team.

Discharge summaries were sent to the patient’s GP following surgery.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

People’s health needs were assessed as part of pre-operative processes, including in relation to their appropriateness for day surgery. Assessments helped staff to identify people’s support needs, and this included lifestyle factors and their recovery from surgery. Staff gave advice that included the promotion of healthy lifestyles. For example, patients undergoing vascular day surgery were encouraged to do gentle walking and increase the amount daily.

The service routinely monitored people’s care and treatment to continuously improve it.

There were effective approaches to monitor people’s care and treatment and their outcomes. The trust operated a schedule of national audits relating to a broad range of issues relevant to surgery. However, these were not all relevant to the day surgery undertaken at Queen Mary’s Hospital.

Trust wide metrics for anaesthesia and perioperative medicine as part of the Getting It Right First Time (GIRFT) programme showed that service performance did not comply with the GIRFT standard in most metrics. The service was also an outlier for wrong skin lesion surgery between April 2023 and March 2024, which included surgery at Queen Mary’s Hospital; however, we saw evidence of improvements being implemented to address this and prevent future incidents. However, there were effective approaches to monitor people’s care, treatment and their outcomes. Audit schedules were set up for 2024-2025 to assess a wide range of patient care.

Local audits were undertaken to monitor and improve patient outcomes. These included monitoring of areas such as fasting times and audits of local safety standards. We saw that between August 2024 and February 2025 fasting times averaged just over 2.5 hours within the surgical treatment centre, with most people fasting for between 2 and 4 hours pre-operatively. Audits of safety standards showed consistently high adherence to safety requirements. Improvements were made when safety issues were identified, including a ‘no photo, no surgery’ amendment to local standards in relation to removal of skin lesions to minimise the risk of the incorrect lesion being removed.

The trust also monitored incidents where patients had to return to theatre due to complications. There had been no reported incidents relating to day surgery at Queen Mary’s Hospital surgical treatment centre.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Written consent was appropriately sought from patients in line with guidance and recorded on consent forms. Forms included the identification of risks and a record these had been discussed with people before signing them. We reviewed written consent forms and saw these were completed and signed appropriately.

People told us staff explained care and treatment to them in a way they understood, and we observed staff requesting consent to undertake assessments and post operative monitoring.

Staff understood the process and requirements for assessing whether a patient had the capacity to make decisions about their care in relation to the Mental Capacity Act (MCA) 2005. Staff received training on the Mental Capacity Act and Deprivation of Liberty Safeguards, compliance across anaesthetic, scrub and recovery teams at Queen Mary’s Hospital was at 100% which was above the trust target of 85%.

Staff followed the trust policy and procedures when a patient could not give consent. We reviewed the consent and Mental Capacity Act (2005) policies, which was based on recognised guidance and appropriately up to date and reviewed.