Queens Hospital

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• 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

This means we looked for evidence that patient’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question as good. At this assessment the rating has remained the same. This meant people’s outcomes were consistently good, and patient’s feedback confirmed this.

The service planned and delivered patient’s care and treatment with them, in line with legislation. The service supported people to live healthier lives. Patient’s rights around consent was respected when delivering person-centred care and treatment.

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.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

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

The service used National Institute for Health and Care Excellence (NICE) guidelines to ensure care was evidence-based. The risk assessments staff used were evidence-based and widely used and recognised across healthcare.

There were internal systems to ensure policies and procedures were designed in line with current national legislation and evidence-based good practice. Clinical protocols and treatment were based on guidance from bodies such as the NICE.

Staff were experienced, qualified, and had the right skills and knowledge to meet the needs of the patient group.

The Same Day Emergency Care (SDEC) service delivered care in line with evidence‑based practice. Staff followed established clinical protocols for patients presenting with chest pain, deep vein thrombosis, and other routinely managed clinical conditions.

Fluid balance charts monitoring was completed as required. Nutritional assessment documentation was available in folders at patients’ bedsides. Nutritional assessments were completed on admission and reviewed weekly, or more frequently depending on the patient’s condition.

The evidence showed a good standard. The service worked well across teams and services to support patients. They made sure patients only needed to tell their story once by sharing their assessment of needs when patients moved between different services.

Staff held regular and effective multidisciplinary meetings. Staff worked closely with specialist teams, including the dementia care team, and were supported by vulnerable persons ambassadors and other role‑specific ambassadors. This collaborative approach helped ensure patients received coordinated and person‑centred care.

For example, ward 6 was a 20‑bedded ward with an adjacent 10‑bedded cardiac care unit. Staff worked well together across nursing and medical teams in both areas. The ward manager promoted a positive safety culture by communicating openly and sharing learning from incidents with staff.

The respiratory team had a positive working relationship with the critical care outreach team and liaised with them regularly to support the management of deteriorating patients.

Staff shared information about patients at handover meetings within the team. During the medical ward round on AMU, staff were observed discussing patients’ care plans in a clear and structured manner.

There was 7-day access to x-ray, Computed tomography, magnetic resonance imaging, ultrasound, echography, and pathology. The service followed the NICE guidelines for the reporting of imaging. Imaging results were generally reported by radiologists. Radiologists contacted the relevant clinical teams directly to communicate any urgent or unexpected findings arising from scans. Staff monitored patient transitions and movement between teams. Virtual wards had access to diagnostic tests and point-of-care testing.

Staff described good collaboration with other hospital departments to support patient discharge and onward care. SDEC also supported ED during periods of overcrowding by accepting suitable patients, helping to improve patient flow across the hospital.

The service had established effective links with local GP surgeries, which enabled patients to be referred directly into SDEC. This supported timely access to care and helped reduce pressure on the emergency department.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

The evidence showed a good standard. The service routinely monitored patient’s care and treatment to continuously improve it. They ensured most outcomes were positive and consistent, and that they met both clinical expectations and the expectations of patients themselves.

Staff monitored care effectiveness and used findings to improve outcomes. The service participated in national clinical audits. Managers and staff conducted repeated audits to improve patient outcomes.

Staff carried out an excellence in care audit, which included both monthly and daily audit activities. These audits supported ongoing monitoring of care standards and enabled staff to identify areas requiring improvement in a timely manner. Pain management audits demonstrated high compliance for pain assessment and care planning (generally above 90%) but identified inconsistency in the use of pain charts and documentation of pain relief outcomes, which dropped to approximately 55–75% from January to November 2025 in some areas, and was subject to improvement actions through governance processes.

The SSNAP score summary shows that patient‑centred care performed worse than other locations in 6 out of 7 domains. For team‑centred care, 2 out of 7 domains were below average, and 3 domains had no data available in the 2025 audit. Staff said an action plan had been implemented to address the identified challenges and support sustained improvement.

The trust had systems to support evidence-based practice in the recognition and management of sepsis. Local audits showed 67% compliance with completion of sepsis six documentation in patients at risk of developing sepsis, which is below the 90% target set. However, audits demonstrate that 82% of deteriorating patients at risk of developing sepsis received IV antibiotics within 1 hour, and 96% of patients medically confirmed septic received IV antibiotics within 1 hour, above the 90% target. Performance was monitored through trust metrics and reviewed by governance groups to promote continuous improvement. A Sepsis Improvement Plan (October 2025 to March 2026) set out clear, evidence‑aligned actions to improve early recognition, timely treatment, audit processes, and oversight, demonstrating a structured and proactive approach to patients’ safety. Patient falls causing moderate or severe harm remained within target (0.136 per 1,000 bed days against a target of 0.147).

Compliance with core patient safety and care bundle measures was consistently high throughout the review period from January to April 2026. Performance remained particularly strong in falls risk assessment, timely escalation of confusion to medical teams, continence assessment follow-up, appropriate footwear provision, and the maintenance of clutter-free environments, with these indicators predominantly achieving or remaining close to 100% compliance. Mobility assessments and timely physiotherapy referrals also demonstrated sustained high performance overall; however, a slight reduction was observed in March 2026.

The evidence showed a good standard. The service told patients about their rights around consent and respected these when delivering person-centred care and treatment.

When patients lacked capacity, staff made decisions in their best interest, recognising the importance of the person’s wishes, feelings, culture and history. Staff made referrals to the Independent Mental Capacity Advocate service for patients who were ‘unrepresented’ (did not have friends/relatives) and lacked capacity to make significant decisions. Patients were transferred to a medical ward where required decisions could be made, and best‑interest meetings were arranged in line with the Mental Capacity Act. Staff implemented DoLS according to approved documentation.

Staff received Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) training. They understood relevant consent and decision-making requirements. Staff knew how to access policy and advice on these topics. Managers monitored compliance with the MCA and made necessary changes.

We reviewed a patient’s clinical record and found clear evidence of regular reviews by both the responsible consultant and the palliative care team. A Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form was completed, current, and documented within the patient’s notes.

Patients we spoke to said that consent had been obtained from them prior to care and treatment and procedures had been explained to them. Patient files we reviewed showed that consent had been obtained, discussed, and reviewed.

Staff supported patients to be actively involved in decisions about their care. For example, a patient told us they were very positive about the care they received and said staff consistently involved them in decisions about their care. They told us staff sought their permission before carrying out interventions and clearly explained what was happening. Although the patient was happy for doctors to make clinical decisions on their behalf, they felt respected and included throughout their care.