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Queen Elizabeth The Queen Mother Hospital Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 7 May 2021

We carried out an unannounced focused inspection of the emergency department at Queen Elizabeth The Queen Mother Hospital following the ‘Resilience 5 Plus’ process. The ‘Resilience 5 Plus’ process is used to support focused inspections of urgent and emergency care services which may be under pressure due to winter demands or concerns in relation to patient flow and COVID-19.

We did not inspect any other services as this was a focused inspection in relation to urgent and emergency care. We did not enter any areas designated as high risk due to COVID-19. The inspection framework focused on five key lines of enquiry relating to critical care, infection prevention and control, patient flow, workforce and leadership and culture.

We previously inspected the emergency department at Queen Elizabeth The Queen Mother in March 2020 as part of our comprehensive inspection methodology. We rated it as Requires Improvement overall.

We spoke with 20 staff across a range of disciplines including lead nurses, senior nurses, healthcare assistants, department consultants, trust grade doctors, junior doctors, matrons, ambulance crews, the care group head of nursing, and the care group clinical director. We attended department safety huddles and a patient flow meeting.

As part of the inspection, we observed care and treatment and looked at eight care records. We analysed information about the service which was provided by the trust.

You can find further information about how we carry out our inspections on our website:

Inspection areas


Requires improvement

Updated 7 May 2021


Requires improvement

Updated 7 May 2021



Updated 7 May 2021


Requires improvement

Updated 7 May 2021


Requires improvement

Updated 7 May 2021

Checks on specific services

Medical care (including older people’s care)


Updated 21 December 2016

We found the medical services at the QEQM Hospital good because;

  • The trust had a robust system for managing untoward incidents. Staff were encouraged to report incidents and there were processes in place to investigate and learn from any adverse events. The hospital measured and monitored incidents and avoidable patient harm and used the information to inform priorities and develop strategies for reducing harm.
  • The trust prioritised staff training, which meant staff had access to training in order to provide safe care and treatment for patients.
  • There were systems in place to maintain a clean and therapeutic environment. Staff effectively managed infection control and maintained the environment appropriately.
  • Medical care was evidence based and adhered to national and best practice guidance. Management routinely monitored that care was of good quality and adhered to national guidance to improve quality and patient outcomes.

  • Patients were supported through consultant led care and effective delivery of care through multidisciplinary teams and specialists. There were clear lines of accountability that contributed to the effective planning and delivery of patient care.

  • Staff treated patients with kindness and compassion.
  • The trusts average length of stay for both elective and non-elective stays were better than the England average for the majority of medical specialities.
  • There was good provision of care for those living with dementia and learning difficulties. There were support mechanisms and information available to take individual patients needs into account.
  • The trust had clear corporate vision and strategy. The trust included the opinions of clinicians, staff and stakeholders when developing the strategy for medical services. Staff felt engaged with the direction of the trust and took pride in the progress they had made to date.
  • The trust had clearly defined local and trust wide governance systems. There was well-established ward to board governance, with cross directorate working, developing standard practices and promoting effective leadership. The trust acknowledged they were on an improvement journey and involved all staff in moving the action plan forward.


  • There was a shortage of junior grade doctors and consultants across the medical services at the QEQM Hospital. This meant that consultants and junior staff were under pressure to deliver a safe and effective service particularly out of hours and at night.
  • We found there were nursing shortages across the medical services. The situation had improved due to the use of agency and bank staff. Although the trust had recruited overseas nurses, there remained staffing shortages on the wards.
  • Staff did not always complete care records in accordance with best practice guidance from the Royal Colleges. We found gaps and omissions in the sample of records we reviewed. The trust did not have a robust system in place to audit, monitor and review care records to ensure they always gave a complete picture of the assessments and interventions undertaken.
  • The trust did not have adequate maintenance arrangements in place for all of the medical devices in clinical use. This was a risk to patient safety and did not meet MHRA (Medicines & Healthcare products Regulatory Agency) guidance.

  • The trust had not completed its audit programme. This meant the hospital was not robustly monitoring the quality of service provision. The hospital performed poorly in a number of national audits such as the stroke and diabetes services.
  • We found that the hospital was not offering a full seven-day service. Constraints with capacity and staffing limited the responsiveness and effectiveness of the service the hospital was able to offer.
  • Patients’ access to prompt care and treatment was worse than the England average for a number of specialities. The trust had not met the 62-day cancer referral to treatment time since December 2014. Referral to treatment within 18 weeks was below the 90% standard as set out in the NHS Constitution and England average for six of the eight specialties from June 2015 to May 2016.

  • The hospital had improved the number of bed moves patients had during their stay. However, a fifth of all medical patients moved wards more than once during their stay. This meant the hospital transferred some patients several times before they had a bed on the right ward, which put additional pressures on the receiving wards.

At our last inspection, we rated medical services as Requires improvement. On this inspection we have changed the rating to good because of improvements in incident reporting, staff training, infection control, staff engagement and ward to board governance.

Services for children & young people


Updated 28 February 2019

We rated services for children and young people as inadequate at Queen Elizabeth the Queen Mother Hospital.

Safety was a concern with insufficient action being taken when risks were identified. There was inconsistent care and recognition of deteriorating patients. The provision for children with mental health problems was under resourced and failed to protect the child, other children or staff. There were significant shortfalls in the prevention and control of infection and of medicines management.

The trust did not consider the needs of children and young people as being paramount when planning and delivering services. The needs of children undergoing surgery, the needs of children with learning disabilities and the needs of 16 to 18-year-olds were particularly poorly considered.

Staff workload was stretched beyond a sustainable level and this was evident in the interactions between staff and from some staff to patients. It was commendable that the children’s emergency department nursing and medical staff continued to provide compassionate and gentle care to the children and their families when they were so busy.

The oversight and governance of services for children and young people was weak. Inconsistencies and incomplete data meant there was false assurance to the board about the quality and safety of care provided.

Critical care


Updated 18 November 2015

We found appropriate and effective reporting and learning from incidents and Morbidity and Mortality (M&M) meetings. Patients were cared for in a clean, well maintained and safe environment. Staff demonstrated good awareness of infection control and there were systems in place to minimise the risk of health acquired infections.

Staffing levels were sufficient to meet people’s needs and consultants provided cover in line with the national recommendations. There was also adequate access to diagnostic and screening services out of hours. The care delivered in the unit reflected best practice and national guidance. There were systems in place to measure patient outcomes and the quality of the service provided. Care needs were risk assessed and the unit could demonstrate a track record of delivering harm free care. The CCU had procedures in place to ensure the safe storage, handling and management of medicines. Documentary evidence demonstrated that patients received their medicines in a timely manner and reasons for omission were clearly documented. Pharmacy support was provided as well as regular reviews and internal audits. Safety thermometer data was collected and collated and used to improve and drive service change. Data was displayed in a public area which meant it could be accessed by those who wished to view it. We found an adequate supply of serviced equipment to enable staff to care for their patients.

Staff demonstrated an established approach to multidisciplinary working with other specialists in the Trust and showed us how they could obtain treatment and care for patients with complex needs, including psychology assessments. The needs of people with delirium or dementia were met by well-educated staff but the Confusion Assessment Method for ICU (CAM-ICU) was not routinely used as an assessment tool. Training was provided on a rolling basis for nursing staff and a dedicated team ensured that trainees and new students were well supported and had the opportunity to develop. Leadership on the unit was found to be strong and effective.

End of life care

Requires improvement

Updated 5 September 2018

Our rating of this service stayed the same. We rated it as requires improvement because:

  • Incidents were not being reported on the trusts electronic reporting system. For example, the practice of placing two deceased patients in a fridge space designed for one had been happening during particularly busy periods. Although a risk assessment had been carried out and the matter had been escalated, it had never been reported as an incident.

  • We did not see a comprehensive record of a formal mental capacity assessments having taken place. A patients mental capacity was mentioned in the records, and on the do not attempt cardio pulmonary resuscitation orders. There was no face-to-face seven day service. The Palliative Care and end of life care service operated Monday- Friday 9am – 5pm. There was a 24 hour a day, seven day a week advisory line available for all hospital staff out of hours from the local hospice.
  • The trust participated in the End of life care Audit: Dying in Hospital 2016 and performed worse than the England average for all of the five clinical indicators. The trust scored particularly poorly for the measure, “Is there documented evidence that the needs of the person(s) important to the patient were asked about?”
  • Capacity issues within the mortuary led to processes for storing the deceased that did not ensure that people’s dignity was respected during care after death. We were told, and were shown a table that demonstrated that this had happened during the winter, specifically once in February and 16 times in March.
  • Complaints relating to the care of patients at the end of life were reviewed by the end of life care board and themes identified. However, it was not clear how these were shared with staff in a way that ensured lessons were learned and care improved.
  • There was written material available for patients and their relatives regarding end of life. However, these were not available in any languages other than English.
  • The challenges facing the service were known to the leaders and the mechanisms were in place for improvements to be made. However, action plans lacked details of how the improvements would be achieved.
  • A formal agreement with the hospice regarding the provision of palliative care consultant cover had still to be finalised despite being in preparation for at least 18 months.


  • Fridge temperatures in the mortuary were monitored remotely through a system that could be accessed wherever there was access to the internet. A mobile phone app that linked to this system was available to the mortuary manager. This meant that temperatures could be monitored 24 hours a day, seven days a week.
  • We found evidence that teams from different disciplines worked well across the hospital and weekly palliative care multidisciplinary team meetings were held at the Queen Elizabeth the Queen Mother Hospital.
  • Staff treated patients and their relatives with kindness, dignity and respect. Staff were always willing to give relatives the time they needed to explain what was happening and what would happen next.
  • Staff dealing with families that had recently been bereaved were conscious of the needs of those people. We saw that staff allowed relatives as much time as they needed to be with their loved ones soon after death.
  • Family members of patients approaching the end of life had access to a large, clean and welcoming room where they could rest, prepare meals, sleep and wash so they didn’t have to leave the hospital site.
  • Chaplaincy services were available for those that requested it and could be provided by chaplains of different faiths as well as those with no faith.
  • The leaders of the service were visible and approachable to all staff that dealt with patients approaching the end of their life.
  • Staff described a positive working culture where there was a belief that all staff had the opportunity to contribute to the care of those patients approaching the end of their life.

Outpatients and diagnostic imaging


Updated 18 November 2015

The Outpatient department was well led and had improved since implementing an outpatient improvement strategy. Despite the strategy being relatively new, the department was able to evidence improvements in health records management, call centre management, referral to treatment processes, increased opening hours, clinic capacity and improved patient experience through structured audit and review.

Although there was still improvement required in referral to treatment pathways, the outpatients department and trust demonstrated a commitment to continuing to improve the service.

As a part of the strategy, the trust had reduced its outpatient services from fifteen locations to six. We inspected five of these locations during our visit.

Managers and staff working in the department understood the strategy and there was a real sense that staff were proud of the improvements that had been made. Progress with the strategy was monitored during weekly strategy meetings with the senior team and fed down to department staff through staff meetings and bulletins.

Outpatients and diagnostic imaging departments at Queen Elizabeth Queen Mother Hospital were providing safe care to patients. There were systems in place, supported by adequate resources to enable the department to provide good quality care to patients attending for appointments.

Evidence based assessment, care and treatment was delivered in line with National Institute for Health and Care Excellence (NICE) guidelines by appropriately trained and qualified staff.

A multi-disciplinary team approach was evident across all the services provided from the outpatients and diagnostic imaging department. We observed a shared responsibility for care and treatment delivery. Staff were trained and assessed as competent before using new equipment or performing aspects of their roles.

We saw caring and compassionate care delivered by all staff working at outpatients and diagnostic imaging department. We observed throughout the outpatients department that staff treated patients, relatives and visitors in a respectful manner.

Nurse management and nursing care was particularly good. Nurses were well informed, competent and went the extra mile to improve the patient’s journey through their department. Nurses and receptionists followed a ‘Meet and Greet’ protocol to ensure that patients received a consistently high level of communication and service from staff in the department.


Requires improvement

Updated 5 September 2018

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The service had not taken sufficient action to maintain the premises and equipment in main theatres. Leaders were aware of safety concerns regarding lack of maintenance of some of the premises and equipment in main theatres but had failed to address this.
  • Nursing staff in day surgery theatres did not have had a sufficient level of safeguarding children training in line with national intercollegiate guidance.
  • Medical and dental staff failed to meet the trust’s mandatory training target of 85% between January and December 2017 for any of the six required modules. Nursing staff also did not meet the 85% target for information governance training.
  • Nurse staffing in the main surgery recovery areas did not meet the Royal College of Nursing standards during paediatric operating lists. This was because there was not at least one registered children’s nurse on duty in the recovery area during children’s operating lists.
  • The service sometimes had insufficient nursing staff on the surgical wards to meet patients’ needs. Nurse staffing shortages did not feature on the risk register. This meant the service might not have had sufficient oversight of this risk.
  • The service did not have assurances staff always stored refrigerated medicines within the manufacturer’s recommended range to maintain their function and safety.
  • Referral to treatment times (RTT) for admitted pathways for surgery were worse than the England average. In December 2017, 57% of patients were treated within 18 weeks, which was worse than the England average of 72%.
  • Governance meetings were not given sufficient priority. Clinical governance meetings did not regularly take place, and there was poor attendance from staff.
  • The trust values did not appear to have been embedded amongst staff. Most staff we asked were unable to tell us the trust values, despite them being included in staff appraisals.


  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with staff to continuously improve patient safety.
  • When things went wrong, staff apologised and gave patients honest information and suitable support. This was in line with the duty of candour regulation under the Health and Social Care Act (Regulated Activities Regulations) 2014.
  • Staff kept records of patients’ care and treatment in line with Nursing and Midwifery Council and General Medical Council guidance and standards. Records were clear, up-to-date and available to all staff providing care.
  • The service used safety monitoring results well. Staff collected safety thermometer information, such as rates of falls, pressure ulcers and catheter-acquired urinary tract infections and shared it with staff, patients and visitors.
  • The service carried out assessments of risks to patients and took action to lessen risks such as falls and pressure ulcers. We saw evidence of regular observations of patients using an early warning system and action taken to escalate any deterioration.
  • The service provided care and treatment based on national guidance and best practice. The service carried out audits to check staff followed internal policies and guidance.
  • Patients had good outcomes following surgery. Results from national audits showed the service performed well, with patient outcomes about the same as other NHS acute hospitals nationally.
  • The service made sure staff were competent for their roles. Managers appraised staff performance, and we saw evidence of meaningful appraisals. Competency records we reviewed provided assurances staff had the skills they needed to do their jobs.
  • Staff of different kinds worked together as a team to benefit patients. We saw positive examples of multidisciplinary working between different staff groups, including doctors, nurses and therapists.
  • Staff obtained patient consent in line with national guidance and legislation. Staff understood their roles and responsibilities under the Mental Capacity Act 2005. They knew how to support patients who lacked the capacity to make decisions about their care.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • Staff provided emotional support to patients to minimise their distress.
  • Staff took account of patients’ individual needs. The service took action to meet the needs of different patient groups so they could access the service on an equal basis to others.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results. The service shared learning from complaints with relevant staff to help drive continuous improvement.
  • Managers across the trust promoted a positive culture that supported and valued staff. Staff generally spoke positively of the culture and described positive working relationships with colleagues and managers.
  • The service took action to actively engage with staff and seek their views through focus groups and open forums.
  • The service had a strong focus on training and developing its own staff. The service had recently introduced an “improvement journey” programme to support nurses recently promoted from band five staff nurses to band six junior sisters/charge nurses. The service hoped this would help fill some of the nursing vacancies by helping improve staff retention.
  • The service had some recent areas of innovation. This included a tool for ward clerk post-discharge telephone calls and a smartphone application for orthopaedic patients called “my journey”. The application, which was due to be rolled out two weeks after our visit, supported patients on their journey from pre to post-operative. The application reminded patients of their medications and exercises to support them as they prepared for, and recovered from, surgery.

Urgent and emergency services

Requires improvement

Updated 7 May 2021


Requires improvement

Updated 28 May 2020