All inspections: Queens Hospital - Care Quality Commission

Date of assessment. 11 November 2025. This was a scheduled assessment as diagnostic imaging has never been inspected at Queen’s Hospital Burton. We looked at all quality statements across the Safe, Effective, Caring, Responsive and Well Led key questions.

Diagnostic imaging refers to non-invasive procedures using technology to create visual representations of the body’s internal structures. This aids medical staff in diagnosing, treating and monitoring diseases and injuries. During our inspection we visited: accident and emergency x-ray and computed tomography (CT), outpatient department X-ray and CT scanners, breast clinic, maternity outpatients, magnetic resonance imaging (MRI) and fluoroscopy. Accident and emergency X-ray and CT scanners are used to quickly check for injuries after sudden illness or accidents, while outpatient X‑ray and CT scans are done during planned appointments to investigate symptoms. Breast clinics provide tests for breast concerns, and maternity outpatients support routine pregnancy check‑ups. MRI creates detailed images of the body without radiation, and fluoroscopy is a moving X‑ray that shows how parts of the body work in real time.

Following this assessment, we rated the service as Good.

During the inspection we spoke with members of staff including radiographers, radiologists, physicists, imaging assistants, sonographers, receptionists, and managers. We also received feedback from patients who were using the service.

The service demonstrated a strong learning culture where people felt able to raise concerns, and staff routinely reported incidents which were investigated thoroughly. People were protected from harm through effective risk management.

Facilities and equipment were clean, safe, and well maintained.

Care was aligned with current evidence and good practice, and people were given clear information to support healthy living and to help them make informed decisions about their treatment.

Care was delivered with compassion and kindness. Staff treated people with dignity and respect and supported one another.

However, staff did not always feel supported by leaders and in some areas. Some staff felt they didn’t have the right mix of people with the right skills to do the job properly.

We undertook an assessment of the outpatient services at Queens Hospital Burton and Royal Derby hospitals on 11 and 12th November 2025. These assessments were carried out as the provider was last inspected in 2019, under a previous inspection model. Therefore, we conducted a comprehensive assessment of this service group at these locations.

On this inspection, we inspected outpatient A and B areas which encompassed a wide variety of clinics including gynaecology, ear, nose and throat (ENT), general medicine, rheumatology, cardiology, respiratory, dermatology and surgery. We also looked at activity in the ophthalmology, urology and orthopaedics outpatient clinics which were in a separate building, known as the treatment centre.

The service had made improvements in the key areas of safe and well led since the last inspection. We rated this assessment service group as good overall.

Outpatient leaders encouraged a positive culture of safety. At this inspection we found that staff had completed relevant mandatory training and leaders had made plans to maintain staff numbers and improve succession planning. Staff understood how to protect patients from abuse and recognised incidents and reported them appropriately. The environment was clean and tidy. We saw an improvement in infection control since the last inspection and the department handled medicines and prescriptions safely and securely.

Staff assessed patients’ conditions and provided treatment promptly which meant patients had more positive outcomes. Patients’ care and treatment was tailored to their individual requirements. Staff monitored patients’ outcomes and worked together to provide support and guidance which helped patients with their ongoing recovery.

The service cared for patients with compassion, kindness, dignity and respect. Staff treated patients as individuals and tailored their care to their specific needs. Patients had choice over their treatment and staff were quick to respond to their changing needs. Outpatients staff had received the appropriate chaperoning training, and this was pro-actively offered to patients. This showed an improvement since the last inspection. Leaders were approachable and cared about colleagues’ wellbeing and staff were encouraged to develop in their careers.

Access to outpatient clinics was straightforward and patients generally experienced positive outcomes. Patients were involved in planning and receiving their care which meant this met their personal circumstances. Staff ensured that information was shared with other agencies to enable continuity of care. Relevant information was provided in a way people could understand, and patients could provide feedback and raise concerns. Clinic availability had been expanded to provide a more accessible service for patients

Leaders promoted a positive culture which enabled staff to develop and were encouraged to speak up if they had concerns. However, some staff felt that there was still inconsistency with information sharing across teams in different specialty clinics, but work was underway to improve the cross-specialty communications and long-term effectiveness of the department.

Teams worked closely with other services and local communities to build relationships and improve people’s care. Leaders encouraged innovation within the departments to enhance staff and patients’ experience.

Date of inspection: 11 November 2025.

Queens 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. This was the first inspection of Outpatients and Diagnostic Imaging using the single assessment framework. The services were rated as good. Following this inspection the rating at Queens Hospital has improved from requires improvement to good

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.

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.

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.

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 of critical care at Queen's Hospital Burton on 13 March 2025.

Queen's Hospital Burton has two critical care areas 'Pod A' and 'Pod B' with 14 beds available for intensive care and high dependency patients. There are isolation rooms available There is a multidisciplinary approach to patient care. The unit has a critical care outreach team who provide support to deteriorating patients throughout the hospital.

Pages 1 to 3 of this report relate to the hospital and the ratings of that location, from page 4 the ratings and information relate to maternity services based at Queens Hospital.

We inspected the maternity service at Queens Hospital as part of our national maternity services inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

Queens Hospital Burton is the principal provider of acute hospital services for the residents of Burton upon Trent and surrounding areas including South Staffordshire, South Derbyshire and Northwest Leicestershire. It provides a range of maternity services including both antenatal and postnatal ward as well as an antenatal clinic. There are approximately 2700 deliveries each year, with caesarean sections and options for pool-based birth.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out an announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

The trust is part of the University Hospitals of Derby and Burton NHS foundation trust.

We reviewed the rating of the location therefore our rating of this hospital stayed the same

Queens Hospital is rated requires improvement in Safe and Well-Led and good in Effective, Caring and Responsive.

We also inspected 1 other maternity service run by University Hospitals of Derby and Burton NHS Foundation Trust. Our reports are here:

Royal Derby Hospital - https://www.cqc.org.uk/location/RTGFG

How we carried out the inspection

We provided the service with 2 working days’ notice of our inspection.

We visited Maternity assessment Unit (Triage) Labour ward / Delivery Suite the antenatal and postnatal wards.

During the inspection we spoke with 20 staff including the Head of Midwifery, Obstetricians, Doctors and Midwives. Attended handover meetings and reviewed 6 records.

We received more than 307 ‘give feedback’ on care forms through our website, with 58% (n177) of the feedback being positive with the remainder 42% (n130) being negative. Feedback received indicated women and birthing people had mixed views about their experience. There were themes around negative experiences and interactions with staff, lack of consent, staff causing women to feel anxious or burdensome, long wait times and limited information on their treatment. We received feedback about women and birthing people reported being asked to remain at home instead of attending the Maternity Assessment Unit (MAU) but after they had attended, they were told they should have attended earlier. Positive comments described staff as knowledgeable and attentive, with the ability to act decisively when required in order to ensure women and babies were kept safe.

Following our onsite inspection, we spoke with senior leaders within the service; we also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

We carried out a short notice announced focused inspection at Queens Hospital Burton on 30 July 2020. During the inspection, we inspected falls assessment and management across both the medicine and surgery core services. This was in response to concerns which were initially raised following serious incidents that had happened at the trust.

We also reviewed discharge processes as a result of concerns raised prior to the inspection about communication upon discharge.

We visited medical wards, ward 4, 5 and 8 as well as the discharge lounge and ward 19, which was a trauma and orthopaedic ward. We chose these locations based upon intelligence received prior to our inspection. We spoke with 18 members of staff, including healthcare support workers, nurses including ward manager grade and therapy staff. We did not speak to any patients. We reviewed 16 patient records and 10 discharge records and observed staff providing direct care to patients.

Focused inspections can result in an updated rating for any key questions that are inspected if we have inspected the key question in full across the service and/or we have identified a breach of a regulation and issued a requirement notice or acted under our enforcement powers. in these cases, the ratings will be limited to requires improvement or inadequate.

Previous ratings were not all updated during this inspection. However, the ratings for safe and effective (in medicine and surgery services), and therefore the overall ratings went down. We rated these areas as requires improvement. Please refer to the ‘areas for improvement’ section for more details.

Our rating of services went down. We rated them as requires improvement because:

Staff did not always undertake mental capacity assessments in line with the Mental Capacity Act. Staff did not consistently follow the Mental Capacity Act requirements when patients were deprived of their liberty.
Patients at risk of falls were not always supervised in line with the trust policy. It was not always possible to identify patients who were at a risk of falls without reviewing electronic records. Patients could not always reach their call bells.
Some nursing notes were not detailed enough. Staff did not always find it easy to locate specific information in the electronic records. Staff did not always keep detailed or contemporaneous records of patients’ care and treatment.
Staff did not always follow risk assessment recommendations when using bedrails.
Not all staff were trained in relevant mandatory training modules in line with the trust’s training target.
Lessons learned from outside of the direct ward area, were not always shared with all staff. Due to COVID-19, staff had fewer opportunities to meet, discuss and learn from the performance of the service.
Not all staff were aware of the support systems in place (falls group) to ensure effective care packages were received by patients.
Some processes related to falls were not yet consistent across the trust. Many actions taken to reduce falls were still in progress at the time of our inspection. The trust gave inconsistent information about how staff should manage some risks.
We found inconsistencies in the information that was cascaded to staff from senior leaders about incidents. Some senior staff were not fully aware of their accountabilities in line with managing serious incidents.
Not all staff were wearing personal protective equipment in line with national guidance.

However, we also found:

Leaders were using systems to identify and escalate falls risks and review falls performance to reduce their impact. They were working towards implementing and embedding effective governance procedures throughout the service in relation to falls.
The design of facilities, premises and equipment kept people safe. Staff were trained to use the equipment. Staff completed and updated risk assessments for each patient and removed or minimised risks.
There was enough rostered staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
Staff kept records of patients’ care and treatment. Electronic records were stored securely and available to staff providing care.
Staff recognised and reported incidents and near misses. Managers investigated incidents. When things went wrong, staff apologised and gave patients honest information and suitable support.
Manager supported staff to become competent for their roles. Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. Where patients had capacity to consent to care and treatment, staff supported patients to make informed decisions about their care and treatment.
The service was inclusive and took account of patients’ individual needs and preferences. Staff mostly made reasonable adjustments to help patients access services. They coordinated care with other services and providers.

We have not taken the previous ratings of services at Burton Hospitals NHS Foundation Trust into account when aggregating the trust’s overall rating. CQC’s revised inspection methodology states when a trust acquires or merges with another service or trust in order to improve the quality and safety of care, we will not aggregate ratings from the previously separate services or providers at trust level for up to two years. During this time, we would expect the trust to demonstrate that they are taking appropriate action to improve quality and safety.

We rated them as requires improvement because:

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.
Mandatory training, safeguarding training, mental capacity act training and role specific training rates were variable across all staff groups.
Morbidity and mortality governance was variable with sporadic representation from some teams and inconsistent evidence of investigation and lessons learned.
Some services did not have 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. There was a reliance on temporary staff to cover staff vacancies in some areas
Changes to the leadership and governance structures since the acquisition were not yet fully embedded; information technology systems had not been integrated, service guidelines and standard operating procedures were not always up to date or aligned to the new trust and systems to extract and separate data were not well developed.
Medicines and medicines stationery were not always stored securely and managed in accordance with local policies.
Some services did not have suitable premises and patient’s security had not been considered. However, the trust took immediate action and put into place measures to ensure premises were secure. In critical care there were unmitigated fire safety and security issues despite on-going escalation through annual risk assessments.
Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) forms did not always contain sufficient evidence that mental capacity assessments had been carried out or considered.
Managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care. However, staff did not fully understand the new structure since the acquisition and were not aware of future plans for the service.
The approach to continually improving the quality of some services and safeguard high standards of care was not robust, however we saw plans in place to make improvements.
Culture was variable across some services.

However:

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
The majority of services, controlled infection risk well. Staff kept themselves, equipment and the premises clean. They mostly used control measures to prevent the spread of infection.
Staff cared for patients and women with compassion. Feedback from patients and women confirmed that staff treated them well and with kindness.
Most services managed patient safety incidents 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.
Most services provided care and treatment based on national guidance.
The trust had a vision for what it wanted to achieve and workable plans to turn it into action.
Managers at all levels, and in most areas, had the right skills and abilities to run a service providing high-quality sustainable care.
Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
Services took account of patients’ individual needs and staff were committed to meeting patient’s personal and emotional needs in addition to their clinical needs.

Queens Hospital

All Inspections

During an assessment of Diagnostic imaging

During an assessment of Outpatients

During an assessment of the hospital overall

During an assessment of Maternity

During an assessment of the hospital overall

During an assessment of Critical care

During an assessment of the hospital overall

22 August 2023

During an inspection looking at part of the service

30 July 2020

During an inspection looking at part of the service

From 29 January 2019 to 15 March 2019

During a routine inspection