Queens Hospital

Updated 7 November 2025

Queen's Hospital Burton is part of University Hospitals of Derby and Burton NHS Foundation Trust. The hospital is the principal provider of acute hospital services for the residents of Burton upon Trent and surrounding areas including South Staffordshire, South Derbyshire and North West Leicestershire. We carried out an unannounced on site assessment Maternity at Queen's Hospital Burton on 16 December 2024.

At this assessment we assessed 1 assessment service group: Maternity where we assessed 29 quality statements.

We visited the following areas as part of the assessment:

Maternity wards and theatres and labour suite.

Updated 4 April 2025

Date of assessment: 16 December 2024. This was an unannounced assessment to review compliance against the urgent enforcement action we took in August 2023.

University Hospitals of Derby and Burton NHS Foundation Trust provide maternity services for women in Derbyshire at Royal Derby and Queen’s Hospital. This service was last inspected in August 2023 and was required to take urgent action to as the Commission believed a person will or may be exposed to the risk of harm if we did not do so.

The service did not have a coordinated approach for the care they provided. Visible leadership by the obstetric medical team was poor which meant appropriate actions and prompt responses to issues with the service were delayed at times. We were concerned that the system in place to identify, escalate and manage women, birthing women and their babies who require induction of labour was ineffective and not in line with national guidance. Handovers of care were also ineffective as the Situation, Background, Assessment, Recommendation (SBAR) tool was not fully completed or entered in to care records.

However, the trust had met some of the conditions placed on their registration at the inspection in August 2023. Senior midwives were in post, hourly ‘fresh eyes’ were completed hourly during intrapartum care, audits of PPH and MOH were completed monthly. Midwives had completed annual mandatory fetal monitoring training.

The culture within the service did not always promote the values of the trust or support staff to speak up. Whilst leaders had the required knowledge and experience, they did not promote a culture where staff felt empowered to speak up and/or raise concerns.

Updated 10 February 2025

Date of assessment. 13 March 2025. This was a scheduled assessment as the service had not been assessed since June 2019.

University Hospitals of Derby and Burton provide critical care for people in Derbyshire at Royal Derby Hospital and Queen's Hospital Burton. Critical care at Queen's Hospital Burton was last inspected in June 2019 and was rated as requires improvement.

During this assessment we assessed all quality statements across the safe, effective, caring and well-led key questions.

During this assessment we assessed 31 quality statements across the safe, effective, caring and well-led key questions. Following this assessment the rating has improved and critical care is now rated as good.

Staff were positive about the culture of the service and worked well together as a multidisciplinary team to provide safe care in line with best practice. There were clear processes in place for shared learning with a focus on continuous learning and improvement.

The environment was mostly safe and medications were managed appropriately

The service ensured they had the right number of staff to meet people's needs and nurses worked in line with national guidance for critical care nurse staffing, which states one nurse is required for each patient requiring level 3 care and one nurse for two patients requiring level 2 care. However, they had not ensured that staff were trained in line with national guidance. Only 46% of nursing staff had received post registration critical care awards. Although the trust had a clear plan in place to exceed the minimum guideline by the end of 2025.

Staff did not always manage hazardous substances in line with Control of Substances Hazardous to Health Regulations 2002.

Updated 6 June 2019

This was our first inspection since the acquisition, so we cannot compare our ratings with previous inspections. We rated it as good because:

• Patients were protected from avoidable harm and abuse. There were sufficient staff with the right skills and experience available and they worked in suitable premises with enough equipment. Staff managed infection risks and medicines well and there were good processes for assessing and responding to patient risks. There was an open culture in reporting and investigating incidents and apologies were offered when necessary. However, we found that mandatory training rates for medical staff were much lower than required and agency staff new to the hospital were not always given a formal induction or training in the hospital’s electronic patient record system.
• Patients had good outcomes because they received effective care and treatment that met their needs. However not all services were available at weekends and patients received less oversight from senior doctors and had less access to some therapies and diagnostic tests.
• Patients were treated with dignity and respect and both they and relatives were offered the support they needed. Feedback from patients and relatives about their care was positive.
• Patient’s needs were met through the way services were organised and delivered. Services were planned around the local population and in conjunction with other providers and with commissioners. Complaints systems were in place and patients were supported to complain.
• Leadership, governance and the culture of the service promoted the delivery of high quality person centred care. Senior leaders were knowledgeable and visible and staff felt supported. A strategy was in place based on the five Trust objectives. There were good governance structures in place, information supported quality improvements and risks were identified and managed. There was a culture of openness and honesty and a strong focus on learning and improvement.

Updated 6 June 2019

This was our first inspection since the acquisition so we cannot compare our ratings with previous inspections.

Our rating of this service was good because:

• Managers provided mandatory training in key skills to all staff and made sure everyone completed it. Although compliance data provided by the trust showed completion did not always meet the 90% target set by the trust, particularly in relation to medical staff, the overall completion rate was over 80%.
• Staff understood how to protect patients from abuse and worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. We observed good multi-disciplinary working and good liaison with other services such as social care, in relation to child protection.
• Staff controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
• Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary. Early warning scores were used to identify deteriorating patients and staff took the necessary action when the scores indicated that escalation was needed.
• Children’s services had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
• Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care. Paediatric medical staff used paper based records in contrast to the electronic record used by other staff; although this interrupted the continuity of the record, it did not cause any impact on patient care.
• Staff followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time. We found an example of good practice in relation to medicines awareness, in that safety huddles (‘druggles’) were held monthly in children’s services to improve safety of medicines management.
• Patient safety incidents were managed well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance. Staff were working towards accreditation of their services with external organisations that promoted best practice in the care of babies.
• Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other preferences.
• Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate by using suitable assessment tools and gave additional pain relief to ease pain. Staff on the neonatal unit completed audits of pain assessments over two, two month periods and showed improvements in the second audit following the implementation of actions from the first audit.
• Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.
• Although previous performance in national audits were generally in line with or better than the national average, action plans to bring about further improvements were in place. Staff also carried out a range of local audits to assess patient outcomes.
• The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
• Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• The service was working towards the provision of seven-day services. A paediatric consultant was on site seven days a week.
• Staff were aware of their responsibilities for obtaining consent for treatment and the requirements in relation to obtaining valid consent in children and young people. They completed training in the Mental Capacity Act (2005) with special reference to paediatrics.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. We observed staff engaging well with patients and parents in a welcoming and friendly manner, putting them at their ease.
• Staff provided emotional support to patients to minimise their distress. Parents praised the support they received from staff.
• Staff involved patients and those close to them in decisions about their care and treatment. Parents were encouraged to be involved in the day to day care of their child as much as they wished.
• The trust planned and provided services in a way that met the needs of local people.
• Staff took account of patients’ individual needs. Staff took a very person-centred approach to the provision of care and treated everyone as an individual.
• People could access the service when they needed it. There were appropriate systems in place for the referral and assessment of urgent and emergency patients and the accommodation of patients for planned surgery.
• Managers treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff. The timescale for response did not always meet the trust target, however the average response time was 27.3 days against the target of 25 days.
• Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.
• Managers had a vision for what they wanted to achieve. They had a plan for the immediate future and were developing plans for the longer term to bring together the service and move forward, with involvement from staff, patients and stakeholders.
• Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
• Managers took a systematic approach to continually improving the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.
• The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
• Managers engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.
• Managers were committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However,

• The environment with the theatre recovery area was not ideal for children, as they were separated from adults only by a curtain. We also identified an issue with secure exit from the children’s wards, which the trust also identified independently and took action to address.
• Nurses in the adult outpatient department where children were cared for, did not have access to training in caring for children.
• Fluids were sometimes withdrawn prior to surgery for longer than necessary for the well-being of the patient.
• Staff working in adult outpatient departments where children were regularly seen, did not have any children’s training and found it difficult to access courses in caring for children.
• The input of play specialists to the outpatient areas was limited.
• A paediatric radiologist was not available on site and specialist advice was obtained from neighbouring hospitals, although action to recruit was being taken.
• Facilities for children seen in the adult outpatient department and the theatre recovery area could be improved.
• Systems to extract and separate data about children’s services from that of other patients were not well developed. This made it difficult to obtain accurate information and assess performance specific to children’s services. Patient records were managed safely using secure electronic systems with security safeguards and ensuring paper records were stored securely.

Updated 6 June 2019

This was our first inspection since the acquisition so we cannot compare our ratings with previous inspections.

We rated it as good because:

• Staff who provided end of life care said they had received training in safeguarding children and vulnerable adults. Safeguarding training was part of the trust’s mandatory training programme.
• We saw infection prevention and control (IPC) policies and procedures in place that were readily available to staff on the hospital intranet. Infection prevention and control was included in the trust’s mandatory training programme.
• The mortuary had swipe card access and closed-circuit television (CCTV) surveillance to maintain security. The mortuary waiting and viewing rooms were visibly clean, they provided facilities for relatives such as comfortable seating and information booklets about bereavement, the trust’s bereavement service and organ donation programme
• The trust used the AMBER care bundle system. This is a model which provides a systematic approach to management and care of hospital patients who are facing an uncertain recovery and who are at risk of dying in the next one to two months. We saw care nursing care records where the AMBER care bundle was used to assist in the planning and delivery of patient care.
• The trust had a protocol called ‘The five priorities for end of life care.’ The protocol was for the last 48 hours of life and provided guidelines for staff on actions to take such as anticipatory prescribing
• The service had no never events reported for patients’ receiving end of life care. Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. From January 2018 to December 2018, the trust reported no incidents classified as never events within end of life care.
• In accordance with the Gold Standards Framework, MDT meetings took place weekly to ensure any changes to patients needs could be addressed promptly.
• The chaplaincy service provided a 24-hour seven day a week on call service for patients in the hospital, as well as their relatives and loved ones and aimed to see people within the hour.
• The hospital palliative care team (HPCT) provided two outpatients clinics to offer treatment for patients being cared for by the team.
• The trust had good multidisciplinary working relationships with the local hospice to provide support for patients at the end of their lives and advice for the trust staff out of hours, with representatives from local hospices took part in the end of life care steering group meetings.

However:

• During our inspection, we looked at 15 ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) orders across the hospital and found there were inconsistencies in how these were completed. We found that out of 15 DNACPR orders, 11 were not completed correctly (74%).
• Mental capacity assessments were not always completed correctly or in appropriate circumstances.
• The end of life care strategy had vision, values and a strategy which had been developed using a structured planning process in collaboration with staff at the trust. However, the management of the end of life care strategy was not well embedded across the trust.

Updated 6 June 2019

This is the first time we have inspected this service since acquisition. We are not therefore able to compare to past ratings of this service.

We rated it as requires improvement because:

• The service provided mandatory training in key skills to nursing staff, however we were not assured medical staff had sufficient up to date mandatory training.
• There were no registered children’s nurses in outpatients at Burton, access to support from paediatric nurses was sourced through the paediatric wards.
• The approach to managing the deteriorating adult or child outpatient was inconsistent and, in some cases, informal. In outpatients A and B and other clinics at Queens Hospital Burton staff, were unable to explain an escalation policy or confirm that they had seen one.
• We were not assured infection prevention and control procedures were robust. We found inconsistent arrangements to ensure cleaning was carried out. Not all clinics had rigorous arrangements to keep play equipment clean. Hand hygiene audits were not always used to monitor hand washing compliance amongst staff.
• Whilst nursing leaders in outpatients A and B understood the challenges to quality and sustainability, they did not always understand the actions they could take to address them.
• The absence of team meetings at operational level in outpatients A and B meant that incidents, complaints and policies were not discussed collectively or knowledge about incidents elsewhere in the trust shared.
• Nursing leaders had not developed plans to address key workforce issues such as staffing, succession and turnover.
• Culture was variable across outpatient clinics and there was inconsistent use of team meetings and daily briefings for staff to learn about incidents, complaints and policies.

However:

• Outpatient care and treatment in the specialties we inspected was based on evidence from NICE and professional bodies. Specialties participated in national audits and used new technology to improve patient care.
• Technology and equipment was used to enhance care in some services.
• Staff were kind, friendly and polite and we observed them interacting with patients in a compassionate way. They had an understanding approach to outpatients with mental health, learning disability or dementia diagnoses.
• The service was mapping provision to local demand. Specialties reviewed capacity to deliver services on an ongoing basis.
• In most cases outpatients had access to a timely appointment. The service generally compared well for waiting list (Referral to Treatment) and cancer waiting list performance.
• Staff made reasonable adjustments and tailored care to individual needs. They made efforts to coordinate care for patients with multiple appointments.

Updated 6 June 2019

This was our first inspection since the acquisition, so we cannot compare our ratings with previous inspections.

We rated it as good because:

• There were effective processes for incident reporting, investigation and evidence of improved shared learning from incidents.
• There was a good supply and availability of surgical instruments with no recent cancellations of surgery attributed to lack of equipment.
• There was good compliance with infection prevention and control processes and low rates of infection.
• The service worked collaboratively with other trust staff and external agencies to ensure that children and vulnerable adults were safeguarded.
• Nationally recognised assessment tools were used to assess surgical patients’ needs, and appropriate measures taken to reduce risks and manage deteriorating patients.
• Staff at all levels were clear in their responsibilities for safer surgery checks and demonstrated compliance with the required standards.
• Staff were committed to working collaboratively and demonstrated multi-disciplinary working.
• Surgical pathways were planned and delivered in line with referenced national clinical guidance. A clinical audit programme informed service development.
• Staff had the required knowledge, skills and competencies to carry out their roles effectively. Managers appraised staff performance and provided developmental support.
• Patients, relatives, and carers gave consistently positive feedback about the quality of care they received.
• The length of stay for elective and non-elective surgery patients was similar to the national average.
• The trust was focused on reducing referral to treatment backlogs and managing patient access and flow.
• Patients had a similar to expected risk of readmission for elective surgical admissions compared to the England average.
• There were reasonable adjustments in place to support patients living with dementia and those living with a learning disability.
• Staff were largely positive about the integration of services since the trust acquisition in July 2018, and described the leadership team as accessible, supportive, and open to ideas and feedback.
• The service promoted learning and development, and research and innovation. Staff were positive about the support they received to challenge existing practice and try out new ideas.

However, we also found:

• Changes to the leadership and governance structures since the acquisition were not yet fully embedded.
• Compliance with mandatory training and appraisal did not always meet the trust target in all areas.
• There was a reliance on temporary staff to cover staff vacancies in some areas
• Queen’s Hospital Burton and Sir Robert Peel Hospital used a different patient administration and record system to that of Derby Royal Hospital. The two systems functioned independently and were configured differently. Whilst there was no evidence that this caused any problems it had been added to the risk register. Work was in progress to simplify and integrate information technology systems.
• Medicines and medicines stationery were not always stored securely and managed in accordance with local policies.

Updated 6 June 2019

This was our first inspection since the acquisition, so we cannot compare our ratings with previous inspections.

We rated it as requires improvement because:

• Although we found the service largely performed well, it did not meet requirements relating to The Department of Health and Social Care’s standard for emergency departments, meaning we could not give it an overall rating higher than requires improvement.
• Patients were not always protected from avoidable harm. There were handover delays for patients arriving by ambulance.
• Patients could not always access care and treatment in a timely way. Waiting times for treatment and arrangements to admit, treat and discharge patients were worse than the England average and national standard.
• Results in national Royal College of Emergency Medicine audits were highly variable, including poor results in the acute severe asthma audit and the consultant sign-off audit.
• Morbidity and mortality governance was variable with sporadic representation from some teams and inconsistent evidence of investigation and lessons learned.
• Medical staff did not meet the trust standard for mandatory training, safeguarding training and mental capacity act training, rates were particularly variable.
• Although the right number of medical staff were deployed, the service was reliant on locums to fill gaps in the rota, particularly overnight and at weekends.

However, we also found areas of good practice:

• Feedback from patients, we spoke with, confirmed that staff treated them well and with kindness. Patients told us they had been given enough information about their condition and/or treatment in a way that they could understand.
• Major incident and emergency planning had been significantly improved through simulated exercises and more advanced training.
• Staff had developed clinical care to meet the specific needs of the local population, including the elderly and those experiencing mental health problems.
• There was the leadership capacity and capability to deliver high-quality, sustainable care. Leadership within the department was effective, there was one individual taking overall responsibility for the day to day running of the department. Front line staff feet supported, respected and valued by their immediate line manager(s). Staff were engaged and morale in the department was high.
• The service had a vision for what it wanted to achieve and we saw evidence of actions to achieve it.