Queen Mary's 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 checked people’s liberty was protected where this was in their best interests and in line with legislation.

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

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Patient safety incidents were managed well. Staff understood how to identify, report and record incidents and recognised the importance of using information to support learning and improvement.

Between January 2024 and December 2024, the trust reported 7 Never Events in surgery, there were no never events in surgery at Queen Mary's Hospital. Managers investigated when things went wrong and worked together with staff and colleagues to identify improvements. We saw examples of learning and staff were involved in this. This included the development of a new safety checklist. Improved safety actions included the use of mirrors, photographs and additional checks with the patient and staff to ensure the correct lesion was removed.

Staff were consistently able to give examples of discussions, learning and improvement. They understood the requirement for openness and honesty in relation to the Duty of Candour, informing patients when things went wrong and involving them in investigations. We viewed an example where an apology letter was sent to a patient because their surgery had been postponed due to a lack of available equipment. Staff informed the patient of the reason for the error and the action taken to prevent it from happening again.

We reviewed surgical treatment centre team meeting minutes and saw that incidents were routinely discussed. This included incidents that had occurred at other hospital sites.

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

Staff told us there was good multidisciplinary team working within the service. We observed a collaborative approach and staff working well together to manage safety.

There was good communication with patient’s GPs and, where indicated, with other services for patients with enhanced needs. Staff reviewed patient records 1 to 2 days ahead of surgery. This ensured suitability for day of surgery and identify any potential concerns.

There was good continuity of care when patients moved between services. For example, on occasion, where a patient’s recovery indicated they required additional support in emergency situations or where their condition was deteriorating, they would be transferred to St George’s Hospital accident and emergency (AE) department by emergency ambulance. There was a clear deteriorating patient policy in place for this and an anaesthetist accompanied the patient to provide enhanced care during transfer and to provide a thorough handover on arrival at AE.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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.

Staff understood how to access the service’s safeguarding adults and children policy which was up to date and available on the hospital intranet system. The policy included clear guidance on reporting and escalation of safeguarding concerns. Staff told us they could raise safeguarding concerns with senior staff and felt these were taken seriously. They also felt confident accessing the trust’s safeguarding team for advice and support.

All clinical staff were trained to the required level 2 and 3 safeguarding adults and Safeguarding Children Level 2 and 3. The service’s compliance rates in safeguarding training exceeded the hospital’s target of 85%.

Safeguarding posters were visible on the unit and included information on how to raise safeguarding concerns. Staff we spoke to had a good understanding of the different types of safeguarding risk and concerns.

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.

Patients were assessed as to their suitability to receive treatment at the centre and as a day surgery patient. Staff completed individual patient risk assessments including pain, pressure ulcer risk, and moving and handling. From the records we reviewed we saw evidence that assessments had been appropriately completed with patients.

Action was taken to work with patients about specific risks to their health. For example, on the day of our visit to the treatment centre, a patient with an allergy to latex was undergoing surgery. A risk assessment had been undertaken in discussion with the patient. Actions were put in place, including adapting the theatre schedule to mitigate against any interruptions and signage on theatre doors reminding staff of the risks. Other assessments included pain, skin integrity and where appropriate due to the nature of the surgery, venous thromboembolism risks.

Staff monitored the stability of patients using the national early warning scores (NEWS2). In addition, level of consciousness scores was used in relation to assessment of the level of sedation of patients, including during their recovery. We saw that monitoring of patients post operatively included frequent observations, starting at 5-minute intervals for the first 30 minutes post operatively then moving to every 15 minutes. Staff we spoke with were aware of escalation protocols for deteriorating patients. They routinely increased the frequency of observations when NEWS2 scores indicated this.

There was an additional anaesthetist working within the surgical treatment centre, known as a ‘floating’ role to assist with any unwell or deteriorating patients. When necessary, patients requiring additional support post operatively were sometimes transferred to St George’s Hospital. They were transferred by emergency ambulance and accompanied by an anaesthetist to ensure continuity and a sufficient handover of care. The service recorded transfers using their incident reporting system. We saw that 7 transfers had occurred since April 2024. These were for issues such as managing patients’ airway, pain, blood pressure and abnormal blood results and cardiac concerns.

The service used the National Safety Standards for Invasive Procedures 2 (NatSSIPS2) eight sequential standards for the safer surgery checklist effectively. We reviewed audit data for Local Safety Standards for Invasive Procedures (LocSSIPs) and NatSSIPs2 and found that all specialties at Queen Mary’s Hospital achieved 100% safer surgery compliance in relation to the required checks, with the exception of urology that achieved 98%.

The service detected and controlled potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care.

During the inspection we visited the surgical treatment centre. We looked at the environment which included, a staff room, changing areas, waiting areas, consultation rooms, theatres and anaesthetic rooms, preparation rooms, scrub areas, utility areas and the recovery room. The treatment centre had been constructed in 2021 and had recently had a refurbishment of the ventilation system. The service had suitable premises that were well maintained. However, managers told us there had been some challenges with the premises relating to the use of a generator and 2 episodes of generator failure. Risk assessments had been carried out and there were appropriate business continuity arrangements in place to reduce the impact of this. There were ongoing processes for review of these arrangements.

Environmental risk assessments were carried out, for example, in relation to health and safety and fire safety. There were appropriate checks in place that included fire alarm testing and water safety testing.

The environment was free from clutter and well ordered with good use of storage space. There were no environmental hazards identified during out visit. Fire escapes and exits were free from clutter and easily accessible. Substances hazardous to health were stored in a locked Control of Substances Hazardous to Health (COSHH) cupboard in a clinical area only accessible to staff.

The environment was suitably secure. Theatres were accessed using no touch sensors and the treatment centre was accessible using allocated swipe cards or through the manned reception area.

Emergency trolleys were easily available within the service. We checked the emergency trolleys in the theatre and recovery areas and found that they were secured with a plastic snap lock, so it was clear if someone had accessed the resuscitation equipment. Equipment in emergency trolleys was checked either daily or monthly and we saw evidence of these checks. We also checked consumable items such as defibrillator pads, needles and syringes and found they were sealed and in date.

Electrical equipment such as defibrillators and suction machines had up to date electrical safety tests.

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

Managers planned and reviewed staffing levels. Staff told us that staffing was good, with appropriate levels and mix of skills. Nursing and theatre staffing was planned to ensure 2 qualified and 1 operating department assistant or healthcare assistant covered each theatre and there were 6 registered nurses and additional nurse associates planned to ensure 8 or 9 staff working in recovery. We reviewed rotas and saw that planned staffing was consistently achieved. There was minimal use of bank or agency staff.

There were sufficient medical staff to keep people safe and meet their individual needs. Theatres were staffed by 3 anaesthetists, 2 participating in theatre lists and a third who was available to support recovery and in the event of a deteriorating patient. There were no medical staff vacancies impacting the Queen Mary’s Hospital surgical treatment centre.

New staff undertook competency-based training and assessment. There were 2 practice educators providing support across 2 days a week. This included supporting healthcare assistants to complete the care certificate and mentor and assessor support to all staff. We viewed competency frameworks for staff in relation to scrub practitioners, recovery practitioners and leadership roles. These incorporated induction programmes and learning agreements.

Staff received training appropriate to their role. Mandatory training rates exceeded the trust’s 85% target. The surgical division achievement rate was 90%. Mandatory training included safeguarding, infection control, resuscitation, moving and handling and information governance.

Staff told us they had opportunities to develop their skills and complete training outside of mandatory training requirements. Staff we spoke with told us they had received an appraisal in the last year. Achievement rates for appraisals across the theatres and anaesthetics division were 85% for non-medical staff and 84% for medical staff. This was below the trust target of 90% but we saw there was close monitoring of compliance. Appraisal completion for staff working within the surgical treatment centre at Queen Mary’s Hospital was 100%. Team leaders at Queen Mary’s Hospital told us all non-medical staff had received an appraisal in the last year.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of infection spreading and shared concerns with appropriate agencies promptly.

The environment of the surgical treatment centre was clean and well maintained, with suitable furnishings. One of the theatre nurses was the lead for infection prevention and control (IPC). There were up to date cleaning records demonstrating regular cleaning of the environment. Cleaning audits were carried out and showed 100% compliance in November and December 2024.

We observed staff appropriately washing their hands and there were relevant hand hygiene posters at hand washing areas. There was access to hand sanitisers throughout the service. Monthly audits of staff hand hygiene were carried out. These consistently showed that the service exceeded the trust target of 95% compliance between October and December 2024.

The trust infection control policy was in date and accessible on the hospital intranet. Staff had support from the St George’s site IPC team to help manage any IPC issues. Staff told us there were regular IPC walk arounds and microbial testing on the theatre air quality.

There were no reported surgical site infections (SSI) at the surgical treatment centre. Audits of the intra and post operative SSI prevention was carried out in the centre biannually. Records showed that SSI prevention compliance was 100%.

There was easy access to personal protective equipment (PPE) such as gloves and aprons. We observed staff wearing appropriate PPE in theatres.

Equipment was decontaminated and cleaned as appropriate in line with trust policy. We saw the use of ‘I am clean’ stickers that indicated equipment had been cleaned after use.

Waste management was handled in line with national standards. Recognised colour coding was used. Waste bins were foot pedal operated and used appropriately. Sharps bins were labelled and not overfilled.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Patients were given appropriate information about their medicines in relation to the treatment they received. This included pre-operative information about changes to their usual medicines and post operative information about issues such as pain control. There were processes for assessing patients on admission to the surgical treatment centre and this included a review of their medicines and relevant medical history.

The trust pharmacy team were available to support safe and secure management of medicines. We saw that medicines were stored safely, within locked cupboards where the keys were only accessible to authorised staff. Controlled drugs were stored in line with legislation and records of administration were completed appropriately.

Monthly audits of medicines were carried out in theatres and recovery. Performance was consistently at 100% for the surgical treatment centre. Variance in November 2024 included that records of fridge temperature checks were not recorded on the appropriate form and that a medicines cupboard was not appropriately secured. We did not observe these issues during our inspection and records were appropriately maintained of fridge temperatures.