Queens 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 people were protected from abuse and avoidable harm.

Leaders encouraged a positive culture of safety based on honesty and openness. Staff understood how to protect patients from abuse and recognised incidents and reported them appropriately. Leaders made sure there were enough competent staff to keep patients safe. Staff worked together within the department and across their specialties to provide good patient care. The environment was clean and tidy, and staff managed infection risks effectively. The outpatient departments had effective systems to handle medicines and prescriptions safely and securely. 

At our last inspection we rated this key question requires improvement. At this inspection the rating has changed to 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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify good practice, but it was not always clear if this was embedded. Staff within specific departments worked closely, but cross divisional learning was sometimes limited.

Staff followed a clear process to report, investigate and review patient safety incidents. There were clear reporting processes to ensure managers had oversight of incidents and submitted statutory notifications appropriately. Staff knew what incidents they should report and knew how to escalate and document them. Staff members told us there was a positive reporting culture, which encouraged shared learning and helped manage risks.

All staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if things went wrong. Duty of candour cases were also shared with the relevant patients’ GPs.

Data showed there had been 301 incidents in the outpatient department in the previous 12 months from November 2024, with 4 incidents resulting in moderate or serious harm to patients. Leaders had told us they had created action plans and issued guidance to staff following these incidents to prevent recurrence. However, it was not clear if leaders checked these actions were embedded.

Staff received feedback from investigation of incidents through emails and bulletins. These were also discussed in staff meetings. However, some clinic leaders said that learning from other specialties was not always shared, which some felt was leading to silo working. One staff member told us that their team used video to help with reflective practice in their training for patient care, which they said was very helpful.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff within the service made sure there was continuity of care when people moved between different services, although this was not always seamless.

The outpatient referral and admission processes were well documented and ensured that the right information about the patient was shared between services. Patients told us that referrals to outpatients were usually through their GP’s and that this was an easy process.

Nursing staff, healthcare assistants and healthcare practitioners in outpatients worked closely together and there were good working relationships between clinical and reception staff. Some staff had raised concerns with managers that communications between the outpatient clinics and other departments was not always perfect. This meant that sometimes staff had to track down information when patients arrived from other areas. Patients told us handovers within the specialties were good but there were sometimes issues when services were in different locations.

Staff told us they liaised with other services within the hospital to provide continuity of care. They also offered patients information about external services and groups to promote their ongoing recovery.

Staff told us they could call resuscitation teams and access appropriate equipment to manage a patient’s rapid deterioration. However, staff in clinics away from the main building of the hospital told us that to transfer a patient to the emergency department, they were required to call for an ambulance which could lead to delays in treatment.

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 quickly and appropriately.

The service had clear safeguarding policies for both adults and children, which were accessible to all staff. All staff were required to complete safeguarding training. Mandatory training records showed that clinical staff were expected to achieve Level 3 safeguarding competency, and over 90% were compliant with this requirement at the time of our inspection. Non-clinical staff were expected to achieve level 1 safeguarding competency. Whilst staff received safeguarding training in line with trust policy these requirements were not in line with national best practice which states that non clinical staff who had contact with adults and children should be trained to level 2, however these staff were only trained to level 1. This was due to be reviewed with a plan in place to increase training for non-clinical staff to level 2.

All staff we spoke with knew how to make a safeguarding referral and did this when appropriate. They said the safeguarding team was very responsive.

Staff knew how to identify adults and children at risk of, or suffering, abuse. Staff told us there had been few incidents in outpatients departments where concerns had been raised and handled. A staff member told us about a young person who had been missing their appointments and there was concern around their wellbeing. Nursing staff got in touch with the GP and their parents to help resolve the issues so that they resumed their appointments.

Patients told us they felt safe within the department and confident they could raise concerns about safeguarding with staff.

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.

The service provided guidance to enable staff to assess risks to patients’ health, including their mental health and to be aware of the signs of deterioration.

Staff told us they discussed the benefits and risks of treatments and procedures with patients at initial appointments in the outpatient department. Some clinics made use of treatment decision documents to help patients make informed decisions about their care. Staff continued the discussions with patients about the benefits and risks at regular stages of their treatment.

Outpatient clinic staff did not have specific standard operating procedures for care for deteriorating patients and so followed the trust wide policy for care for these patients. We saw posters displayed to remind staff to consider and manage suspected sepsis. Staff were able to check on patients while they were waiting for appointments. However, in one clinic area, the lack of waiting room space and reception staff meant that at times, patients were not always monitored by staff.

Staff considered patients’ personal circumstances when discussing treatment options and ensured patients were aware of the risks of procedures and treatment. Families and carers were included in these discussions to help patients consider these risks.

Patients said consultants took the time to explain their condition and encouraged them to ask questions. They said they could raise concerns and that they were given choices about treatment. Patients were able to tell staff if and how their care was improving their condition.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff monitored equipment to ensure it was safe for use. Housekeeping staff told us that if they noticed any broken equipment or items which required maintenance, they would inform the estates team. If there were any issues which could impact patient care, they would tell nursing staff immediately.

Staff could access appropriate emergency equipment as needed. We saw that resuscitation trolleys were positioned in easily accessible places. We checked these trolleys, and all items were in date. We saw evidence that staff conducted daily and weekly checks and these corresponded with records in the audit book. The trolleys had security tags attached to them to ensure that they had not been opened by any unauthorised person. The use and auditing of these tags were in line with trust policy.

Consulting rooms and corridors were visibly clean and tidy, although corridors in some areas were used as patient seating areas outside of consulting rooms, which meant there was less space for emergency equipment or cleaning apparatus to be moved along them. A lack of space in the waiting area assigned for two separate clinics meant that patients were also seated or standing in corridors.

We saw servicing dates on equipment were regularly checked and testing of electrical equipment was up to date. Most utility rooms were uncluttered, clean, and in rooms where medicines were kept, we noted that temperatures were regularly checked. Oxygen cylinders were securely stored, in date and checked regularly. Sharps boxes were correctly assembled, not overfilled, stored securely and all in date. Clean utility rooms containing medication and Control of Substances Hazardous to Health (COSHH) cabinets were kept secure, and contents were in date.

Fire exits were clearly marked, and staff knew the correct procedures to follow in an emergency. There was a fire safety warden for the department, who conducted weekly checks of fire extinguishers and fire exits. Records of these checks were kept securely.

The service conducted annual environmental audits and 2025 data showed that these were 100% compliant across clinics. Staff also carried out health and safety assessments and there were health and safety risk registers for each department.

The outpatient departments had various trust specific risk registers covering environment which were regularly reviewed. We saw that a safety risk check conducted in September 2025 of the outpatient department showed the environment, fire safety, security and welfare of staff had been checked and any issues escalated to managers or relevant departments.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Leaders ensured staff had the right skills and qualifications to do their job effectively. Staff worked together well to provide safe care that met people’s individual needs.

Staff in specialty clinics were managed by specialty team leaders, such as those in surgery, oncology, cardiology. These leaders ensured that all staff were suitably experienced and competent in their specialities. Staff also worked with outpatient leaders to develop skills relevant to their role in that specific department. These leaders told us they looked to best practice and service policies relating to skillsets, as they did not currently have national guidance about these for outpatient staff.

Leaders told us they reviewed activity from the previous year. They adapted methodologies from the trust’s “Right People” programme and worked with specialty teams to measure and forecast workload to ensure the right staffing levels and effective skill mix across the service.

Clinics were currently fully staffed with consultants, nursing staff, healthcare assistants and allied health professionals. However, staff in the urology and orthopaedic clinics told us that the lack of reception staff had led to an increased workload for clinical staff to manage appointments. This impacted patient flow and added to delays in appointments.

Staff told us staffing levels were appropriate and people had the right qualifications and experience. They also said that many colleagues had worked in the departments for a long time and that there was a low turnover of staff. Data showed that vacancy rates were low in the outpatient A and B clinics between November 2024 and October 2025 and at the time of inspection, the teams had all clinical staff vacancies filled.

Leaders told us they had a high use of bank staff at the last CQC visit in 2019. They had worked to reduce this since then and increased the number of permanent staff. They no longer used agency staff and the use of staff on the bank rota was almost negligible.

Colleagues from other areas within the specialty could provide cover, and staff members could be flexible with their working hours. This meant staff could arrange a better work-life balance. However, staff sickness throughout the 12 months prior to the inspection was 16.5%. A third of those were on long-term sick leave. This was higher than the overall trust target of 4.5% sick leave.

Data from December 2025 showed an overall 94% completion of mandatory training by staff in outpatients. Staff were reminded to refresh their training at regular intervals to maintain knowledge and skills in line with best practice. However, some staff felt they lacked time to do specialist training.

Staff received regular appraisals of their work. Data showed that the average appraisal compliance for all outpatients’ staff was 88.3% against a trust target of 95% between November 2024 and October 2025.

Staff told us teams worked efficiently and provided effective care for patients. Patients noted that there were enough staff to provide care and answer questions. They remarked on the friendliness of reception staff and healthcare assistants and said they felt confident in the skills and experience of the staff.

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

Staff had access to up-to-date infection prevention and control policies and audit processes. We saw evidence of audits conducted regularly to manage risks of infection. In the 12 months prior to the inspection, the average compliance with hand hygiene audits was 98.4% and infection prevention control (IPC) was 95.8%, across all outpatient areas.

Reception areas and consulting rooms were visibly clean and tidy, and staff cleaned and checked medical equipment regularly. Furniture and equipment were clean and in working order. We saw that staff disposed of sharps bins safely. Posters reminded staff and patients to wash their hands.

Staff followed processes to reduce the risk of infection. Staff were bare below the elbow and washed their hands at appropriate time. They had access to and used appropriate personal protective equipment. Hand sanitisers were available and there were adequate handwashing facilities.

A dedicated housekeeping team cleaned outpatients A and B before the start of clinics each day. This included ‘high and low’ (reaching above and below eye level) cleaning with weekly cleaning behind and under equipment. Managers carried out regular audits of tasks and environments to ensure standards were maintained. Cleaning staff used "I am clean" stickers on equipment and areas of patient contact to show which items were ready for use. We saw evidence of weekly water flushing records in some outpatient areas and spill kits were available.

Leaders told us there was a local IPC lead in all areas who inspected the service regularly. They conducted monthly checks and quarterly audits across departments. Staff could raise any IPC concerns which would be discussed in staff meetings. Regular meetings were also held with housekeeping teams to ensure appropriate standards of cleanliness and infection control were maintained.

Staff were aware of the latest IPC guidance and could escalate concerns about infection control in daily meetings or raise them with their IPC lead. We saw information boards including advice and updates about IPC in staff areas.

The service had recently set up a monthly decontamination user group meeting for outpatient teams to discuss the management of sterile equipment used in the department.

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

Staff followed national guidance and trust policies to manage and reconcile medicines, including controlled drugs, although most clinics did not keep these in their departments.

Medicines and prescription pads were stored securely and safely. A daily log was kept of standard NHS prescription forms. The in-house pharmacy team reconciled this log daily. Staff carried out daily checks of room and refrigerator temperatures in areas where medicines were stored. Medical gas cylinders were full, in date and securely stored. Medicines were stored within the correct temperature ranges.

We reviewed sample of medicines in emergency trolleys and in medicine cabinets. All were stored correctly and within expiry dates. There were no controlled drugs kept in the clinics we checked.

Patients told us they were able to request appointments to discuss changes in medication with staff. They confirmed they were able to obtain medication from the in-house pharmacy at the hospital.