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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has stayed the same.

This meant there was not a learning culture that consistently supported recording or learning from incidents. Safeguarding processes did not constantly support staff to have all the information they required to protect women and babies. There were not always enough suitably trained staff. However, there was enough equipment to keep women safe and staff mostly followed infection prevention and control guidance. 

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 did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

There was an inconsistent approach to learning in the service. Staff understood their responsibilities for reporting incidents and were able to clearly describe what should be reported and how to access the organisation's reporting systems. Most staff told us they felt encouraged to report incidents and spoke positively about the incident reporting culture within the hospital. However, not all staff reported incidents in line with the trust incident reporting policy.  Similar concerns were identified at the previous two inspections, and this issue had not been fully addressed at the time of this inspection. Some staff reported they had been actively discouraged from reporting incidents relating to staffing levels and delays in obstetric reviews and all births that did not happen on the labour ward, which did not support a fully open and transparent reporting culture. 

We saw evidence that births that happened outside of the labour ward were not always reported. We found women sometimes delivered in triage but a review of learning from patient safety events (LFPSE) that took place between January and June 2026 found no reports of women delivering in the triage area had been recorded.

Staff did not always report all incidents at the time of them happening. A review of LFPSE between January and June 2026 showed there were delays in reporting incidents for example; 1 incident where the time to reporting had taken 1580 days; 9 incidents had taken between 115 to 316 days to report and 59 incidents where the time taken to report had been between 7 to 115 days. We also saw that the numbers of LFPSE reports did not always correspond with number of national institute for health and care excellence (NICE) maternity staffing red flag events. These delays mirrored delays we found at our last inspection of this service. 

Senior leaders explained some of these incidents were identified following audits of care including after action reviews, so while they may not have been recognised or reported on at the time of the incident there were systems and processes to ensure incidents were identified and learnt from. The trust told us that only 1% of incidents (17 of 1,453) that should have been reported within the required timeframe were not submitted on time, where the need for reporting could reasonably have been identified at the point of occurrence.

Staff generally described learning from incidents and gave examples of changes to practice and systems. However, the service did not consistently share feedback and learning across the workforce. Some staff told us that non-rotational staff received feedback following incidents, but rotational staff did not routinely receive the same information.

Incidents that resulted in patient harm were reviewed using the Patient Safety Incident Investigation (PSII) framework. We reviewed 3 PSII safety action plans and noted that the findings of these were shared with the person reporting the incident. The plan also contained information about how lessons learnt were to be shared with all staff. Maternity and Neonatal Safety Investigations (MNSIs) were reviewed alongside other patient safety learning processes.  In addition, a significant number of incidents were subject to After Action Reviews to identify safety learning.

The service used safety huddles and weekly newsletters to share learning. However, staff told us they did not consistently read emails, which limited the effectiveness of this approach and meant the service could not be assured that learning reached all relevant staff.

The service had introduced a quick response (QR) code system to support reporting of missed breaks. However, some staff told us they chose not to use the system as they had not received feedback following previous submissions and were unclear how the information was being used. This reduced confidence in the effectiveness of the reporting mechanism and may have contributed to under-reporting.

Staff demonstrated a good understanding of the Duty of Candour and were able to provide examples of being open and honest with women and their families when things had gone wrong. 

The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Not all systems at the time of our inspection worked effectively to keep all women safe. The telephone triage service was shared between Queen's Hospital Burton and the Royal Derby Hospital. While most callers were answered promptly, the longest recorded wait was 37.5 minutes and 370 calls were abandoned, which may have affected timely access for some women.

There was an increased risk of deterioration going unrecognised, delays in receiving timely treatment, and poor outcomes for women requiring urgent or time-critical interventions because the service had no dedicated medical cover for triage. As a result, some women experienced significant delays before medical review; during the inspection we observed one woman who had waited 10 hours to see a doctor. A review of LFPSE incidents between January and June 2026 identified 4 women who self-discharged whilst awaiting a medical assessment and three further incidents involving delays to time-critical care. In addition, there was no formal process to ensure women who self-discharged were contacted, followed up, or had their ongoing safety assessed, increasing the risk that deteriorating conditions or unmet care needs would go unidentified.

There was no formal documented process to ensure women received results of blood tests in a timely manner.  Staff said women’s names were written on a white board and this was used as a reminder to look up results and inform women. There was a risk that this informal system would not be effective to ensure all blood results were given to women in a timely way. 

Not all women were directed to the right location for their needs when contacting triage or arriving at the unit. Staff told us that they had a different process to Royal Derby Hospital; and that every woman that presented had to be seen by triage before being sent to the most appropriate location for their clinical needs. This meant some women gave birth in triage rather than in the labour ward. We raised this concern with the trust. They informed us that the process for women attending both maternity units was the same and that staff at Queen’s Hospital Burton were not always following the correct policy in place. The trust provided assurances they had discussed this with staff, and that staff working within maternity knew the correct process to follow to keep women and babies safe. 

Not all patient records were updated consistently.  Some staff told us that documenting women’s care was not completed as well as they would have wanted due to the volume of work. Staff told us they often had to update patient records after their shift ended due to time constraints, which meant this was not recorded contemporaneously.

However, the service had a clear referral process to access maternity care at the beginning of pregnancy. Women could self-refer to the service when they became pregnant or be referred by a clinician. The service aimed to book pregnant women in by 9 weeks and 6 days gestation, in line with national institute for health and care excellence (NICE) guidelines which was monitored by the service. Women who were under 16 weeks pregnant were referred to the gynaecological unit. 

Women whose first language was not English were encouraged to attend for a face-to-face triage assessment. They were told that they could just turn up and did not need to call ahead. This meant that they could be examined and there was a reduced potential confusion over symptoms the woman was experiencing. 

Midwifery staff worked with specialist teams to ensure that those with enhanced needs received the treatment they required. The community midwifery teams had access to these records, as did other community-based services. This meant community staff could see details of risk assessments, outcomes of assessments, plans for ongoing care and required follow-up actions, together with information relating to labour, birth and post-partum care. Handovers and safety huddles across the unit involved all relevant members of the multidisciplinary team. Shift changes and handovers included all necessary key information to keep women and babies safe.

Consultants held a full handover at the start of each shift when each woman had a board review using the ‘situation, background, assessment, and recommendation’ (SBAR) framework. In addition to this the consultant led 2 board rounds of anti-natal and post-natal women each day. The board round also included a discussion of theatre care. This was an improvement since our last inspection.

Midwives, including student midwives, attended a midwifery handover at the start of their shift. There was a concise SBAR handover of each woman and any concerns were shared. This was an improvement since our last inspection.

Feedback from staff identified some inconsistencies in safeguarding arrangements. Staff described having a poor working relationship with the safeguarding team and were unable to identify the organisation’s safeguarding lead. This meant staff did not always have a clear understanding of safeguarding leadership and support arrangements within the service.

Not all staff were up to date with their safeguarding training.  Compliance with the trust’s safeguarding training target of 90% was 85% for midwives and 79% for additional clinical services staff; however, compliance among medical staff was lower at 60%. The leadership team was aware of this shortfall and had implemented plans to improve medical staff compliance rates.

Where staff were up to date, nursing and medical staff completed Level 3 safeguarding adults and safeguarding children training. The training programme included key topics such as female genital mutilation (FGM), perinatal mental health, substance misuse, and domestic abuse. However, safeguarding training was not always delivered in line with national intercollegiate guidance. Non-clinical staff who had contact with adults and children had received Level 1 safeguarding training, although national best practice guidance states these staff should receive Level 2 training.

Not all staff were confident in accessing wider safeguarding support. Staff told us they did not have a well-established working relationship with the safeguarding team and were unaware that a safeguarding team was based at the hospital. Some staff perceived the safeguarding team to have a limited presence within the service, partly due to the misconception that the team was located solely at the trust’s other acute hospital site. Despite this, staff understood how to access safeguarding advice, support and supervision through their own midwifery teams when required.

Each morning non-rotational staff received an email with the most up to date information about patients and babies subject to child protection proceedings. Non-rotational staff were unsure how this information was shared with rotational staff during their absence. However, leaders discussed safeguarding concerns during handovers to ensure staff were aware of potential risks and actions needed to keep women safe. Safeguarding information was also accessible through the electronic patient record system.

Staff understood their responsibilities to safeguard people from abuse and knew how to raise concerns. Staff could also describe how they protected people from harassment and discrimination, including those with protected characteristics under the Equality Act 2010. Staff we spoke with were able to describe the safeguarding process, provide examples of previous safeguarding cases and explain how concerns had been escalated. 

The service had a policy for baby and child abduction and a guideline for newborn security. However, it was not clear within the policy how frequently abduction simulation exercises should be undertaken.

The most recent annual baby abduction drill was conducted in June 2026. Feedback from the exercise demonstrated that, although the drill did not proceed as planned, the team used the opportunity to identify learning and areas for improvement. Both positive practice and lessons learned were captured and shared with staff, and an action plan was developed to address the issues identified and strengthen future responses.

The service had plans for a multidisciplinary tabletop exercise involving maternity and neonatal services to be held in September 2026. This will be followed by a live maternity abduction drill to validate the effectiveness of any changes implemented following the tabletop exercise.

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.

Staff mostly completed tools to keep women and babies safe. When babies were born, staff completed newborn risk assessments using recognised tools which they reviewed regularly. Observations of newborns were documented on the EPR. All the newborn observation charts we reviewed were completed, scored, and escalated appropriately when required. 

However, not all women were monitored for clinical deterioration in line with trust policies. Staff used the nationally recognised Maternity Early Warning Score (MEWS) tool to identify women at risk of deterioration. Based on the results of this tool, staff prioritised which women needed to be seen first. Audit data provided by the trust for June 2026 showed 70% compliance for women’s observations being recorded against a target of 90%. This meant staff may not have always had all the information needed to make decisions about women’s risk. However, targets for reviews being completed within appropriate timeframes was 100% compliant.

Staff in the maternity theatre used the World Health Organisation (WHO) surgical safety checklist. Audit data showed compliance of 98% for March and April and 100% for May 2026. Staff also completed venous thromboembolism (VTE) risk assessments. Audit data showed 95.4% compliance in May 2026.

During labour, high-risk women were monitored using a cardiotocograph (CTG). A CTG is a device used to monitor fetal heart rate and uterine contractions. According to the National Institute for Health and Care Excellence (NICE) guidelines, CTG traces should be reviewed hourly by two clinicians (a process known as a ‘fresh eyes’ review), to ensure the baby is safe to continue with labour. The records we looked at showed fresh eye reviews were being completed hourly. Audit data showed 91.2% compliance between October and December 2025. This was an improvement since our last inspection.

Staff communicated with women to help them understand their care and treatment. We observed multilingual posters in patient areas that could be used by women and their relatives to show what language they wanted to communicate in. We also observed posters encouraging women and their relatives to be involved in their care.

Staff gave women and those close to them help, emotional support and advice when they needed it. Staff also made sure women living with mental health conditions and learning disabilities received the care needed to meet all their needs. The service had 24-hour access to mental health liaison and specialist mental health support.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment and facilities supported the delivery of safe care.

We were not assured human tissue was stored securely. We found placentae were being stored in a sluice room that was accessible to patients and other unauthorised individuals. This did not provide assurance that human tissue was stored in a secure, access-controlled environment in line with Human Tissue Authority requirements and the Human Tissue Act 2004. This increased the risk of unauthorised access to human tissue and demonstrated a lack of effective oversight to ensure the safe and lawful storage of biological materials.

The maternity triage area was temporarily located outside the main maternity unit while a new unit opposite the labour ward entrance was undergoing refurbishment. However, staff told us this arrangement had been in place for approximately three years. There was no direct line of sight from the triage assessment area to the waiting room because whiteboards and posters obstructed visibility. As a result, staff were unable to maintain effective observation of women waiting for assessment. This increased the risk that women whose condition deteriorated while waiting may not be recognised promptly, resulting in delays to escalation, assessment and treatment, and potentially compromising patient safety and outcomes.

Staff on the maternity ward told us the emergency buzzer could only be heard within the ward area, unlike the emergency buzzer in triage which could be heard throughout the unit. Staff said no patients had come to harm as a result of this; however, they felt reassured that assistance could be summoned more quickly from other areas if the buzzer was audible across the unit. This created a potential risk of delays in additional staff responding during emergencies, which could affect the timely management of deteriorating women or other urgent clinical incidents.

The maternity unit was kept secure at all times. The unit was open 24-hours a day, 7 days a week. Entry and exit to different parts of the unit was fully secure with double entry systems monitored by ward clerks and maternity staff. All doors were closed, and we observed staff asking for identification before admitting people into areas.

The service had enough suitable equipment to safely care for women and babies. This included cardiotocographs (CTG), equipment to listen to baby’s heartbeat, and observation machines. Facilities staff had serviced equipment when it should have been and all portable electronic devices had been safety tested.

Staff had access to emergency and safety equipment and carried out regular checks on them. Emergency equipment included neonatal resuscitaires, neonatal emergency trolleys, adult resuscitation trolleys, and post-partum haemorrhage boxes. 

Women could reach call bells, and we observed staff responding quickly when they were called. 

Staff disposed of clinical waste safely; we observed sharps bins being filled within a safe limit and clinical and domestic waste being segregated and labelled correctly.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The service did not always ensure an appropriate skill mix to maintain the safety of women using the service. While staffing levels generally met planned numbers, there were occasions when multiple newly qualified midwives undertaking their preceptorship were deployed on the same shift. As a result, the service could not demonstrate that all shifts were consistently staffed by midwives with the required experience, competence, and skills to deliver safe care. This concern was also identified at the previous inspection and had not been adequately addressed.

The service used the Birthrate Plus tool to determine safe staffing levels, with the latest review completed in May 2025. This identified the need for increased staffing on the maternity ward at Queen's Hospital Burton.

On the day of our inspection, the labour ward was 1 midwife down for the day shift and 2 midwives down for the night shift. The maternity ward was staffed to template. Managers used bank staff to cover midwifery staff shortages. However, these shifts were not always filled which meant staff often had to be moved from lower risk areas of maternity such as the maternity ward to work on the labour ward. 

Staff reported a poor skill mix as they had a lot of junior midwives in the workforce. Band 6 staff told us they were often too busy to support junior staff with the development of their competencies. 

Student midwives reported they were not always achieving their placement objectives. There were 4 separate universities who placed student midwives at Queen’s Hospital Burton. During our inspection there was a significant number of student midwives on site all at different stages of their training. We spoke with student midwives who were on their labour ward placement but who had been sent to work in triage or the antenatal and postnatal wards. We were told the final year students were often prioritised on labour ward to achieve their birth numbers.  Student midwives also reported they did not have consistency in mentors, and they were often allocated to a few different staff throughout their placement. This meant the students had to repeatedly inform staff of their learning requirements; and did not have consistent oversight of their development resulting in unnecessary delays in getting their competencies signed off.

Not all staff completed mandatory training. The target for compliance with mandatory and role specific training was set at 90%. Data demonstrated that this target was not met consistently. Compliance with moving and handling training was 66.7%, and 53.3% for hand hygiene training. Pool evacuation training compliance was 86%. Training across the maternity units in saving babies lives was 81.5%, newborn basic life support was 80% compliant. Only training in fetal monitoring exceeded the 90% target at 96.6%

The service had implemented measures to improve staff appraisal rates and monitored compliance across staff groups. Appraisals supported staff development and provided opportunities for managers to review performance, competencies and learning needs. Data provided by the trust showed appraisal rates for nursing and midwifery staff had improved significantly, increasing from 63.8% in February 2025 to 76.6% in June 2026. Medical staff appraisal compliance was high, reaching 97% in May 2026, demonstrating strong engagement with the appraisal process within this staff group. However, appraisal rates for administrative staff had declined over the same period, falling from 83% in February 2025 to 76% in June 2026. Leaders were aware of this reduction and continued to monitor compliance across all staff groups.

Managers provided staff with opportunities for supervision to discuss clinical practice, review care management, reflect on learning and identify development needs. Staff described varying experiences of support. While some staff spoke positively about the support available to them, some Band 6 staff told us opportunities for professional development were occasionally cancelled or postponed due to staffing pressures and the need to provide clinical cover. 

The trust provided us with red flag event data for April to September 2025. There was a total of 143 red flags during this time. A midwifery red flag event is a warning that there may be an issue with staffing. Red flag events are situations such as missed or delayed care, delay between admission for induction and beginning of process, and the coordinator being unable to remain supernumerary. Once a red flag event is highlighted, the midwife in charge should be alerted and if staffing is identified as the cause, action should be taken.

There was adequate 24-hour medical cover. During the day the medical team included a consultant obstetrician, 3 resident doctors, at night there was 1 consultant obstetrician and 2 resident doctors. Staff told us the on-call consultants were always very responsive to calls from colleagues and would attend the hospital whenever necessary. Medical staff told us they had positive relationships with the maternity transformation team and senior leadership team. Both of which were involved in increasing the number of doctors working cross site to improve out of hours cover and changing rota cover to improve the number of medical staff working at the hospital.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly

Not all staff consistently followed the trust’s infection prevention and control (IPC) policies. During the inspection, we observed some clinical staff wearing nail varnish, which was not in line with the trust’s IPC standards and guidance aimed at reducing the risk of infection transmission.  However, staff only wore permitted jewellery, such as wedding bands and stud earrings, in accordance with trust requirements.

We observed most staff adhering to other IPC principles, including appropriate use of personal protective equipment (PPE) and effective hand hygiene practices. Staff had access to handwashing facilities and alcohol hand rub was available throughout the unit. Hand hygiene audit data from April and May 2026 showed 100% compliance.

Clinical areas were visibly clean and had suitable furnishings which were clean and well-maintained. Cleaning schedules were up to date. 

The unit had dedicated full-time members of housekeeping staff. Maternity support workers and midwives also participated in keeping the unit and the equipment clean.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

Antimicrobial stewardship training compliance was low, with only 22.3% of medical staff and advanced clinical practitioners (ACPs) having completed the required training. The trust conducted an audit of antimicrobial prescribing practices, with 22 prescriptions from maternity services reviewed between April and June 2026. The audit identified several areas of poor practice. Only 30% of prescriptions were compliant with trust antimicrobial guidelines, and fewer than 20% of patients had blood cultures taken prior to the initiation of antibiotic therapy. These findings indicated significant opportunities to improve antimicrobial stewardship, guideline adherence, and diagnostic practice within maternity services.

The triage unit did not initially have immediate access to life saving medicines used for the active management of the placenta and reduce the risk of post-partum haemorrhage despite occasions where women delivered babies there. This meant triage staff had to access these medicines from the labour ward. However, following the inspection these medicines were added to the triage area and stored within a fridge as per best practice guidance.

However, staff followed systems and processes to ensure the safe prescribing and administration of medicines. We reviewed six medicine records and found that allergies and weights were consistently documented to support safe prescribing. Medicine administration records were fully completed by staff when medicines were administered.

Medicines were stored securely in locked clinical rooms. Staff monitored room temperature, and refrigerator and freezer temperatures in areas where medicines were stored centrally to ensure medicines remained within the required storage conditions.

Controlled drugs (medicines subject to additional legal controls because of their potential for misuse and diversion) were stored securely. Staff completed daily stock balance checks, and records demonstrated balances were accurate and up to date. The triage unit had 5 controlled drug books in use at the time of inspection. Whilst this is not unusual, there was 1 controlled drug book which predated the existence of the triage unit (3 years). Because of the age of the book there was deterioration of the binding and pages, making it difficult to maintain the record in a condition suitable for a permanent legal document.