St Helier Hospital and Queen Mary's Hospital for Children

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

The service had arrangements in place to keep people safe and manage risks effectively. Staff promoted a positive safety culture and understood their responsibilities for reporting concerns and learning from incidents. Staff managed patient pathways safely; they monitored risks during transfers and worked with multidisciplinary teams to ensure continuity of care. Staffing levels and skill mix supported safe care. Senior medical input was accessible out of hours, and staff could contact critical care outreach teams when needed. Pharmacy teams supported medicines optimisation and discharge planning.

Safeguarding processes were in place, and staff knew how to escalate concerns. They completed checks during admission and discharge planning and contacted the safeguarding team when required.

Staff involved patients in managing risks. They explained treatment plans, updated patients when delays occurred and encouraged questions.

The environment supported safe care. Clinical areas were suitable for the services delivered, and staff managed transfers between departments safely. Staff managed medicines safely; controlled drugs and emergency medicines were checked regularly, and medicines were stored securely.

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 learning culture, supported by established governance processes that ensured learning from incidents and complaints was shared and embedded. Staff were encouraged to raise concerns and contribute to improvements.

The governance structure included a weekly divisional incident review group (DIRG), led by the divisional triumvirate and quality team. The group carried out a monthly review of incident trends reported on the electronic incident reporting system (excluding pressure ulcers). Findings from these reviews were presented at the monthly clinical governance meeting, enabling senior oversight. Staff who reported incidents received feedback, ensuring the learning loop was closed.

The service demonstrated formal and detailed learning from incidents under the Patient Safety Incident Response Framework (PRIRF). Learning from patient feedback and complaints was captured through action plans and shared widely. Themes from complaints, such as delays in making end‑of‑life decisions, gaps in record keeping, and delays in administering medicines, led to targeted actions. These were disseminated during ward huddles and at monthly staff meetings, to reinforce changes in practice.

Staff were actively involved in quality improvement (QI) initiatives to address identified safety risks. Examples included Band 6 nurses leading projects to improve staff knowledge and confidence in sepsis assessment following a survey that identified gaps, and a project in the acute medical unit (AMU) to raise awareness of the importance of early and safe mobilisation to reduce complications and length of stay.

The service had systems in place to support safe care and treatment, and staff generally followed these processes. Escalation and discharge pathways were clearly defined and embedded to support patient flow. This included the daily circulation of lists for patients who were medically fit for discharge or not meeting the criteria to reside. These lists were reviewed by the clinical operations team. Staff held daily transfer-of-care huddles with external partners and senior clinical operations staff to progress discharge plans. For patients with prolonged hospital stays, a fortnightly complex discharge panel reviewed individuals with a length of stay of more than 35 days, with escalation to the senior leadership team for cases requiring complex decision‑making.

Patient flow through the emergency and medical pathways was not always effective, which affected how safely and efficiently people moved through the system. During the visit to the same day emergency care unit (SDEC), we observed patients spending prolonged periods in the area, including one person who reported staying for two nights on a recliner chair and another who had spent 24 hours. The SDEC environment was not designed for overnight care. [AS1] However, owing to capacity pressures, staff used recliner chairs for extended stays. It meant that patients were not always being cared for in facilities appropriate to their needs.

The acute medical unit (AMU) was designed to provide short‑stay assessment for up to 72 hours before patients transferred to a specialist or general medical ward. However, because the general medical wards were frequently operating at full capacity, patients who would ordinarily have moved to these wards remained in the AMU for longer periods. At the time of the assessment, none of the patients stayed in the AMU for less than 72 hours and many exceeded 2 or 3‑week stays. Most patients were discharged directly home from the AMU without progressing into the wider inpatient pathway. This meant the AMU increasingly functioned outside its intended purpose and became disconnected from the usual emergency‑to‑ward flow.

Medical wards were required to “board” patients to create space. A boarded patient is an admitted patient who cannot be moved to an inpatient bed and is therefore held in a temporary location because no appropriate inpatient bed is available. Boarding areas were not designed for ongoing medical care, even though staff worked hard to maintain safety. These areas were prioritised for admissions from the emergency department to relieve pressure there. This sustained pressure on bed capacity and pathway alignment created inefficiencies, increased dependency on non‑specialist areas, and indicated that the service’s escalation and flow structures were not effective.

Some discharge processes were not aligned across the medical wards, which affected how consistently people moved through the system. Staff used the discharge lounge for patients waiting for medicines, transport or family support, but others were discharged directly from their wards. We did not see clear, consistently applied criteria that explained which patients should be transferred to the discharge lounge. This variation meant the pathway for discharge was not always predictable, and ad hoc decisions were made about whether a patient would move through the lounge or leave directly from the ward.

At the time of the inspection, the discharge lounge was operating with increased capacity and extended hours, but it was underutilised. When inspectors visited at 10am, the area was almost empty despite wider operational pressures. This meant the lounge did not consistently support discharge flow from the wards, which in turn limited the ability of staff to release inpatient beds in a timely way. Leaders held regular flow management meetings, but the lack of a clear and consistently applied discharge pathway reduced the effectiveness of these processes.

The management of acutely unwell patients showed both strengths and operational pressures. Audit data indicated that structured sepsis risk assessments had significantly improved across the sites following targeted education and the introduction of the Care Flow sepsis module (electronic, clinical decision support tool integrated into the electronic patient’s records system). Senior clinical decision‑maker review rates for high‑risk sepsis patients also showed sustained improvement, peaking at 85% (September 2023 to March 2025), reflecting consistent prioritisation of early senior assessment. However, timely administration of antibiotics was affected by overcrowding, particularly in the Emergency Department. Fluid bolus delivery within 1 hour was also variable across the trust, averaging between 65% and 68%.

Learning from incidents and complaints informed improvement. Staff identified gaps in documentation, including occasions where pressure damage present on admission had not been photographed in the emergency department or AMU. Learning actions focused on improving the accuracy of admission documentation and ensuring pressure ulcer plans were clearly recorded on discharge letters to support continuity of care. Wider work included distribution of a skin‑damage leaflet to nursing homes and invitations for external staff to attend training, demonstrating collaboration with community partners to support prevention. Related equipment risks were discussed at the Patient Safety and Quality Group, which reviewed an alert on medical beds, trolleys and bedrails and agreed actions to procure appropriate equipment and finalise policy.

Falls prevention was an area of both structured monitoring and identified concern. Quarterly audits were in place, with compliance reports scheduled in 2025. However, at the time of our inspection these reports were not yet available. Staff focused improvement actions on completing risk assessments on admission and weekly thereafter, in line with local policy and mandatory assessment requirements for all adult patients. Awareness materials reinforced the expectation that all admitted patients should receive a falls risk assessment to ensure appropriate care planning.

The service had arrangements to safeguard patients from abuse and neglect. Staff understood their responsibilities and acted promptly when concerns were identified. The trust maintained a safeguarding guide for staff, which clearly outlined categories of abuse and the safeguarding principles under the Care Act 2014, ensuring that staff had access to clear foundational information. Safeguarding referrals for local boroughs were made through the electronic system within the patient record, which documented the local authority’s assessment and protection planning process.

The service proactively managed safeguarding risks for patients with complex needs. For example, staff used a personalised safeguarding care plan for a non‑verbal adult with a severe learning disability, autism, and epilepsy, who was admitted from an emergency department. This plan required reasonable adjustments, including priority triage, prompt transfer to a quiet waiting area, and one‑to‑one health care assistant support between 10pm and 7am. This demonstrated a proactive approach to mitigating the individual’s risk.

There was evidence of governance and strategic oversight. The patient safety and quality group (PSQG) reviewed the group‑wide safeguarding annual report (July 2025), which noted the introduction of new corporate nursing leadership and strengthened assurance processes. The report identified an increase in Court of Protection cases, prompting a closer review of Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) processes. A priority action was the redesign of Level 3 safeguarding training. During conversations with staff, some appeared unclear about the meaning and application of DoLS, often interpreting the term as general safeguarding rather than understanding the specific legal framework, suggesting that further awareness and training was required.

Safeguarding training levels were identified specific to the staff members roles. However not all staff had completed the required training for safeguarding adults with compliance below 50%. The trust had developed a new Level 3 Adult safeguarding package which we were told was ready to be launched. Compliance with completion of this training will be monitored via the training report. Most staff had completed safeguarding children’s levels 1 and 2.

Pathway reviews showed that staff completed safeguarding checks during admission and discharge planning. Staff knew how to access safeguarding advice and described clear escalation routes. Communication between hospital teams and community services supported safe transitions for patients with additional needs.

However, there was an issue with the electronic patient record system. When a safeguarding concern was raised, a flag appeared on the patient’s record, but staff could not view the details of the concern. This meant staff knew that a safeguarding issue existed but were unable to see the nature of the risk without contacting the safeguarding team for clarification. This created a potential delay in understanding the safeguarding concern. We were not provided with evidence of how the risk relating to safeguarding and the electronic patient record system was being mitigated and when the matter would be resolved.

The service involved patients and, where appropriate, their families in decisions about managing risks during their care. Staff explained treatment plans and discussed any proposed changes with patients before proceeding. When delays occurred in diagnostic tests, staff informed patients of the reasons and provided revised timeframes. This helped patients understand the situation and reduced anxiety.

The service had arrangements to identify and manage the complex risks associated with vulnerable people. For example, staff used a personalised safeguarding care plan for a non‑verbal patient with a learning disability and autism. This plan set out the requirement for one‑to‑one support to mitigate the risk of diagnostic overshadowing and relied on family members and support staff to share information about any underlying physical health concerns.

Staff worked with patients to identify needs and risks. Where additional support was required, such as assistance with mobility or medicines, staff documented these discussions and ensured plans were in place. [AS1] In situations where discharge arrangements were complex, staff involved patients and families in planning and checked that they understood the next steps

The service showed a commitment to learning from negative events. Following a formal complaint, the action plan for C3 ward required staff to implement strategies that prioritised patients’ individual needs, values, and preferences to support shared decision‑making.[AS1] Action plans for the coronary care unit (CCU) addressed the need for early engagement with families when making end‑of‑life care decisions. The actions demonstrated that the service was working to strengthen communication pathways and ensure family concerns were acknowledged and responded to in a timely manner as the action plans had not been completed we were unable to assess their impact.

There was evidence that staff encouraged patients to raise concerns and ask questions. Records showed that patients were offered opportunities to discuss their preferences, and staff responded promptly to queries. This supported shared decision‑making and helped patients feel involved in their care.

The service provided care in environments that generally supported patient safety and met the needs of people using the service. Patients were cared for in appropriate clinical areas, and transfers between departments were managed safely. Pathway reviews showed that staff maintained continuity of care when moving patients from the emergency department to acute medical units and onward to ward settings.

Clinical areas were suitable for the services delivered. Spaces were generally of adequate size to accommodate patients, staff, and essential equipment, and supported access for multidisciplinary teams. There were designated areas for handovers and confidential discussions, which helped to maintain patients’ privacy. However, on the acute medical unit, the handover and multidisciplinary team (MDT) room was cramped, with more than 15 staff present during meetings and limited space to move around.

Safety protocols for equipment were in place including periodic portable appliances checks. Staff had access to essential medical devices, and systems were available for reporting faults and escalating equipment risks. Resuscitation equipment was available, checked regularly and had clearly assigned responsibility. Medicines and medical gases were stored securely in line with policy, and staff understood the risks associated with oxygen use.

The annual patient-led assessments of the care environment (PLACE) programme assessed non-clinical aspects of the environment, including accessibility for people with disabilities. An estates plan had been developed to address the identified issues such as repairing damaged walls, cleaning dusty ceiling fans and replacing a cracked sink. Progress with completion of actions was monitored but it was unclear which group or committee any delays were reported to.

The service used established systems to report and address environmental concerns, including processes for the safe management of clinical waste and escalation of issues. Temporary escalation spaces were used when required, and documentation showed that these were subject to risk assessment and provided with essential equipment, including oxygen, suction and emergency kits.

The service operated a temporary discharge lounge located at the rear of the hospital, but directional signage in the corridors had not been updated to reflect this. There were conflicting signs pointing in different directions, one to the former discharge lounge, which created confusion for patients and visitors trying to locate the correct area. The previous discharge lounge, although still signposted, had been repurposed as a waiting space for outpatients requiring transport. We saw a medical fridge in the discharge lounge with visible mould, we escalated this immediately and staff took action to clean it. However, this indicated that equipment checks were not consistently completed and that this environment was not always maintained to the required standard.

The service had arrangements in place to ensure safe and effective staffing across medical care areas. Pathway reviews showed that patients were cared for promptly, and there were no delays in treatment or transfers attributed to staffing shortages. Staff were present during key stages of care, including admission, diagnostic review, and discharge planning, which supported continuity and patient safety.

Leaders monitored workforce indicators, including vacancy, turnover, and sickness absence, and fill rates. Staff fill rate data for May to October 2025 demonstrated strong coverage for registered nursing posts on day shifts, with several wards including A5, C4, and C5 reporting fill rates exceeding 100% which was due to enhanced care being provided within these areas. However, fill rate for non-registered nursing and care staff frequently fell below the 90% benchmark on several key wards.

Staff were appropriately qualified and competent for their roles, and mandatory training was completed and monitored. Training included safeguarding, NEWS2, resuscitation, infection prevention, and medicines safety. Staff also had access to role-specific development opportunities and supervision.

Workforce planning aimed to maintain safe staffing levels across shifts, including nights and weekends, and senior medical input was available out of hours. Staff could access critical care outreach teams when needed. Escalation for deteriorating patients was managed promptly. However, senior clinicians on the elderly care wards told us there was only one medical registrar covering all medical wards between 5pm and 9am, which they felt did not always reflect the acuity and volume of patients on the site.

The trust-wide risk register highlighted the lack of sufficient consultants to provide continuous 24/7 cardiology consultant cover across both sites as a high operational and clinical risk. This had impact on patient safety by increasing the potential for delayed inpatient review and out-of-hours specialist support. The service mitigated this risk through interim measures including a weekend on‑call rota at Epsom, medical on‑call cover for cardiology wards, and access to specialist advice from the St George’s Hospital cardiology on‑call team, while progressing a business case to increase substantive consultant staffing and developing a cross‑site strategy. The acute medical workforce review from November 2025 identified the need for an improved senior skill mix on the medical wards and an additional registrar to support the bedded emergency department area (SDEC).

The service used agency and bank staff when required to maintain safe staffing levels. There was no evidence of over-reliance on temporary staff, and induction processes were in place to ensure they understood local protocols. Staff described feeling supported during busy periods, and there were systems to monitor workload and redistribute resources when necessary.

Staff worked collaboratively with pharmacy, therapy teams, and discharge coordinators to ensure safe and timely care. Despite high workload pressures, the service maintained a clear structure for its senior leadership team for all wards, and its robust use of governance meetings (e.g., patient safety & quality group and divisional governance) ensured that all workforce performance metrics, risks, and audit failings were tracked and discussed at a senior level with clear, documented action plans for mitigation.

The service had arrangements in place to prevent and control infection, and staff understood the importance of these measures. Patients were cared for in clean environments, and there were no concerns raised about infection risks during transfers or admissions. Staff followed expected infection‑prevention practices, such as washing their hands and wearing personal protective equipment (PPE). Where relevant, these actions were recorded in patient notes.

Patients who needed to be isolated because of suspected or confirmed infections were placed in appropriate areas promptly. Staff acted quickly when risks were identified, and different teams communicated well to make sure patients were moved safely and were protected from exposure to others. Reusable medical equipment was cleaned in line with national guidance, and staff knew their responsibilities for keeping equipment safe and clean. Clinical waste and hazardous materials were managed in line with national standards and regulations.

During the assessment, there was an outbreak of a respiratory virus on an elderly care ward. The service responded quickly by limiting access to the ward, stopping visiting and ensuring staff were not moved elsewhere. This showed the team could act promptly and effectively to contain an infection risk.

There was evidence of a structured and transparent approach to learning from healthcare‑associated infections. Minutes from the PSQG (October 2025) showed that rates of hospital‑acquired Clostridioides difficile had trebled since the previous quarter, which reflected a national pattern. Although no lapses in care were found when the service reviewed these cases, the team identified that earlier reporting and earlier isolation of patients could help reduce future risk. There was also an example of learning following a case of MRSA bloodstream infection on the renal ward. The review involved infection‑prevention specialists, ward staff and senior nursing leaders, who met to understand what had happened, share learning and agree on steps to reduce the risk of similar infections in the future. This showed the service took a multidisciplinary approach to infection review and learning.

The service was working to improve how antibiotics were used, which is an important part of preventing infection. Staff monitored antibiotic use closely, and sepsis audits focused on whether antibiotics had been given on time and whether screening tools had been completed. Work was also under way with the trust’s reporting team to develop automated reports through the electronic prescribing system, allowing leaders to track when antibiotic doses had been marked as “not done” and understand whether any patterns needed attention. Staff could already see overdue medicines on the electronic drug chart because they appeared in red, which meant that missed doses were clearly visible to the clinical team.

Staff told us they had training in infection prevention and control (IPC), and the service monitored compliance with mandatory training. Mandatory training compliance data showed that IPC training compliance was generally strong. Most wards demonstrated 100% compliance in IPC Level 1 and 80 - 96% in IPC Level 2, indicating that staff received the required IPC training and that arrangements to support safe practice were in place. There were systems in place for reporting concerns, and audits were carried out to check whether standards were being met.

However, the service did not maintain IPC standards consistently across all medical areas. Internal audits showed a wide variation in performance between wards. Some wards scored within the ‘Requires Improvement’ range, including the coronary care unit at St Helier, showing that core standards had not been reliably met in these areas.

There were also repeated gaps in hand‑hygiene supplies. Some wards did not have alcohol hand gel or wipes available at patient bedsides, even though these were needed for safe care. These gaps meant that staff could not always carry out safe appropriate hand hygiene at the point of care.

Environmental cleanliness and the safe storage of items were also variable. On Frank Deas General Medicine, equipment such as foot stools were damaged in a way that made them difficult to clean properly. A dressing trolley was not labelled as clean, and items such as toilet rolls and mops were not stored safely, which increased the risk of contamination. A separate audit in the cardiac rehabilitation area found a patient trolley that was dusty, although this was equipment that was not used often. Those shortcomings were identified by internal audits and staff took actions to address them.

The service had arrangements to manage medicines safely and effectively. Staff completed medicines reconciliation promptly at admission, during transfers, and before discharge. Pharmacists checked allergy status and patient weight to support safe prescribing, and they recorded this in patient notes.

Pharmacists reviewed prescriptions for accuracy and appropriateness. They checked high-risk medicines, such as anticoagulants, and ensured venous thromboembolism (VTE) prophylaxis followed national guidance. When adjustments were needed, pharmacists worked directly with medical teams to optimise treatment and reduce risk.

Staff used an electronic prescribing system, which reduced transcription errors and supported secure documentation. Pharmacy teams provided advice when staff needed clarification, and notes showed that staff escalated queries and resolved them quickly.

Staff managed controlled drugs in line with legislation and trust policy. They carried out regular checks and ensured emergency medicines were available and ready for use. Staff stored medicines securely and understood the risks associated with oxygen and other medical gases.

Pharmacists supported discharge planning by confirming patients received the correct medication and clear instructions. Staff explained changes to treatment plans and checked that patients understood their medicines before leaving hospital. When patients needed ongoing monitoring, staff referred them to community pharmacy or their GP to maintain continuity of care.

Pharmacy teams carried out medicines’ optimisation audits and shared findings with clinical teams to improve practice. Staff understood these processes and their role in maintaining safe care.

Medicines optimisation processes were monitored. However, we found there were some gaps in adherence and oversight. For example, the action plan developed post an incident on C3 ward, included actions that required staff to follow clinical guidelines for identifying and managing sepsis, such as the Sepsis Six pathway. This action plan had been developed following a failure to comply with the Sepsis protocol was identified. We also noted that action plans had been developed following complaints of delays in medicine administration on wards B5 and C5. These action plans focused on auditing adherence to the five rights (5Rs- right patient, right medication, right dose, right route, and right time) of medicines administration.