Queen Elizabeth The Queen Mother 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

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

The service delivered care in line with national guidance and evidence-based standards, supported by effective governance processes, multidisciplinary working, and effective use of technology. Staff consistently used recognised tools such as National Early Warning Score (NEWS2) and sepsis pathways to identify and respond to patient deterioration, and audit activity drove ongoing improvement. While overall performance and teamwork was good, challenges remained in areas such as patient flow, communication during transfers, consent documentation, and higher-than-expected mortality, indicating opportunities for further improvement.

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

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 people’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.

Care was delivered in line with national guidance. Staff had access to electronic care guidelines. Staff told us this ensured the care they provided was evidence based and in line with National Institute for Health and Care Excellence (NICE) guidelines. The Clinical Guideline Review Panel met as required, based on the volume of clinical guidelines submitted, to ensure timely review and approval. The panel often met twice each month and reported into the Operational Quality Governance Committee.

Minutes of the clinical guideline review panel showed reviewers checked that updated clinical guidelines reflected national guidance, used the approved template, and included clear titles along with accurate authorship, responsibility, version control, and review dates. They ensured relevant specialists were consulted, confirmed ratification at specialty level, verified that references worked, and completed an equality analysis. They also confirmed all sections were fully completed before approving the guideline for publication.

The service used a clinical audit programme to monitor local clinical care and compare performance with national standard. Audit and pilot results drove improvement. For example, a pilot programme allowed nurses from care homes to shadow frailty specialists in hospitals, and vice versa, and stakeholders reported it as a great success. This improved understanding of the needs of frail patients reduced the length of time they spent in hospital. The average length of stay for patients with moderate to severe frailty decreased to 10.9 days, compared with the national average of 12 days. Clinical teams discussed their findings in regular meetings and monitored agreed actions. Local audits included patient care, patient records, patient risk assessment, medicine, equipment, quality, infection control and ward environment.

Staff assessed and met patients’ needs for food and drink and for specialist nutrition and hydration. A national nutrition tool was used to assess a patient’s risk of malnutrition. We reviewed 10 patient records and found the tool had been completed correctly to maintain nutrition and hydration. Staff had access to a dietitian to support patients with complex nutritional needs.

Staff had access to the full range of specialists required to meet the needs of patients. As well as doctors and nurses, the multidisciplinary team (MDT) included occupational therapists, social workers, pharmacists, speech and language therapists, dietitians and clinical nurse specialists. We attended several handover meetings and ward rounds and observed contributions by the MDT that ensured patients received the best clinical care. Important patient information was recorded on a handover sheet. The information included resuscitation status, past medical history, fundamentals of care, therapies, reason for admission, planned treatment and expected date of discharge.

St Margaret’s Ward had a newsletter called ‘Great News’. This included information about a focus on reducing patient falls and skin damage, mandatory training attendance, flexible working and a survey to get to know their colleague better. Wards planned their ward meetings at different times of day to allow all staff to attend. It was also possible to join virtually, and a record of the discussion was shared with all staff.

Managers and the practice development team identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. Managers ensured that staff received the necessary specialist training for their roles.

Managers dealt with poor staff performance promptly and effectively. Staff told us that they could be open and honest with their mangers when they were struggling. All efforts were made to offer a flexible working environment with reasonable adjustments. Staff had access to talking therapy and support via an employee assistance program. There were HR policies in place to support managers to deal with persistent poor staff performance and staff could be members of trade unions if they wished.

We observed that virtual ward staff delivered care in line with the same evidence‑based standards and clinical guidance used within hospital settings, demonstrating consistency in practice and decision-making. Staff followed established protocols and demonstrated clear awareness of best practice guidance. A sepsis pathway and care bundle supported timely recognition and management of patients with suspected or confirmed sepsis, and were used to guide assessment, escalation, and treatment. Staff accessed recognised national delirium guidance and supporting resources and followed evidence‑based standards for the prevention, identification, and management of delirium. The care group audited admissions from the wards to the critical care service to assess compliance with the sepsis pathway and care bundle. The audit showed that staff adhered to the policy when caring for all patients in the care group with a suspected diagnosis of sepsis.

The trust used an electronic patient records system which flagged patients with additional needs. This included patients with complex or communication needs. Staff routinely assessed patients’ psychological and social needs and reviewed this in preparation for discharge.

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

The teams generally had effective working relationships, including good handovers, with other relevant teams within the organisation (for example, care co-ordinators, discharge teams, and specialist teams). Some staff reported that patients arrived from the Acute Medical Unit (AMU) or Emergency Department (ED) without prior notice, leaving the receiving ward unprepared and without key information about their care and treatment plan. This mostly occurred outside normal working hours.

Two Same Day Emergency Care (SDEC) units and a virtual ward accepted patients from ED and community referrals. One unit treated medical patients, while the other focused on people living with frailty, recognising this group can deteriorate more quickly.

The service used the SDEC model to reduce pressure in ED and avoid unnecessary admissions by providing same‑day care, with consultants identifying and transferring suitable patients at the start of each shift to improve flow. SDEC units operated daily from 8am to 8pm, accepting patients until 5pm. The virtual ward operated Monday to Friday, 8am to 6pm, delivering hospital‑level care at home.

Staff held regular and effective multidisciplinary (MDT) meetings. We attended several meetings and found them to be well attended by the entire MDT. There were discussions about the best care and outcome for each patient. Critical information such as mental capacity assessments, Deprivation of Liberty Safeguards status, completion of Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms, patient falls and actions taken and estimated date of discharge.

Staff shared information about patients at effective handover meetings within the team (for example, shift to shift). There were 2 shift changes every 24 hours, and we saw there were detailed patient handovers between teams to ensure continuity of care. Wards had regular safety huddles during the shift to discuss safety related issues to raise awareness with the whole team. The huddles were attended by nurses, health care assistants, doctors and allied health professionals. Notes from safety huddles showed the topics discussed were patient falls, ReSPECT form completion, timing of ward rounds, pilots to improve patient care and medicine incidents.

The hours of service for diagnostic modalities supporting routine and urgent inpatients were as follows: plain film imaging and CT were available 24 hours a day, 7 days a week. MRI services operated from 8am to 8pm, 7 days a week, and ultrasound was available from 8am to 6pm, 7 days a week. Pathology provided a continuous 24/7 service. Referrals were made via the electronic referral system, and in emergency situations, a duty radiologist or pathologist was available to be contacted directly.

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 people’s care and treatment to continuously improve it. However outcomes were not always positive and consistent, and did not meet both clinical expectations and the expectations of people themselves.

Staff used recognised tools to improve the detection and response to clinical deterioration in patients as a key element of patient safety and improving patient outcomes. The team used the NEWS2 tool to detect any deterioration in the patient’s condition.

Unwell patients in the medical department who scored 5 or more on NEWS2 were screened for sepsis. Staff completed the sepsis screening tool and actioned the sepsis bundle. The sepsis bundle referred to a set of urgent treatments—such as administering oxygen, IV fluids, antibiotics, and taking blood tests—required within 1 hour for patients with suspected red‑flag sepsis. When a patient had red‑flag sepsis, teams completed the sepsis bundle within 1 hour of the NEWS2 score and escalated care to a senior doctor. If a patient failed to show clinical improvement after 1 hour of treatment, staff referred them to Critical Care or the Critical Care Outreach team through the on‑call team.

The “Up and About Gets You Out” quality improvement initiative on Fordwich Ward focused on improving patient flow and outcomes by supporting earlier mobilisation. The project changed healthcare assistant working patterns so patients could sit out of bed earlier in the day, improving independence, therapy input and recovery. Since implementation in October 2025, the ward’s average length of stay reduced by 2.2 days.

Feedback from staff and medical teams was positive, and the approach became standard practice. A second phase began in February 2026 to support patients to mobilise to the bathroom where clinically appropriate, with plans to share the learning and approach across other medical wards.

Staff used technology to support patients effectively. Electronic patient records allowed information to be shared quickly and accurately between teams. Clinical audits were recorded and analysed, and the findings informed improvements in patient care. Staff recorded patients’ vital signs on electronic devices, which automatically alerted them when a patient’s condition deteriorated. Blood test results, scans, and X‑rays were also available electronically to the requesting doctor, enabling timely clinical decisions.

The hospital was performing worse than expected in national indicators. Between January and December 2025, the hospital recorded a higher than expected Summary Hospital Level Mortality Indicator (SHMI) score of 1.2, meaning deaths were around 20% higher than expected. This data was for the whole hospital and could not be reported just for the medical service however The Summary Hospital-level Mortality Indicator (SHMI) is a measure that compares the number of patients who die following hospital admission with the number expected, based on national data and patient characteristics. Quality improvement audits had been planned to identify the cause of the higher than expected deaths and an action plan to reduce the number of deaths would be developed.

The hospital collected data about the patient’s journey when in hospital. In the 3 months before the assessment, the hospital’s patient flow data indicated ongoing pressure across inpatient pathways, with variability in admissions and discharge performance suggesting challenges in maintaining consistent throughput. The findings highlight how delays in discharge and bed availability contribute to congestion, emphasising the need for efficient discharge processes and whole-system coordination to maintain patient flow.

The evidence showed some shortfalls. The service did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

Staff took all practical steps to enable patients to make their own decisions. On most of the wards, staff had considered the patients’ mental capacity to make decisions for themselves. Staff told us that on occasions patients suffering from confusion had arrived from the acute medical unit and although staff had assessed that the patient lacked capacity there was no documented record of the mental capacity assessment. The ward staff then completed the relevant documentation.

Staff assessed and recorded patients’ capacity to consent on a decision specific basis and, when patients lacked capacity, the staff made best‑interest decisions that reflected the patient’s wishes, feelings, culture and history. Our review of 10 patient notes showed that mental capacity and consent had been considered and documented correctly.

Do not attempt cardiopulmonary resuscitation (DNACPR) and ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) decisions were appropriate and were made in line with relevant legislation.