13 September 2023
The Queen’s Medical Centre is operated by Nottingham University Hospitals NHS Trust. The maternity service sits within the division of family health and provides a range of services from pregnancy, birth, and post-natal care. There are inpatient antenatal, intrapartum, and postnatal beds available for women. The fetal medicine service is based at both Nottingham City Hospital (NHC) and QMC sites but mainly at the QMC campus.
Maternity services at the QMC are based over 2 floors. Ward B26 is an 18 bedded antenatal ward. Ward C29 is a 26 bedded postnatal ward which includes transitional care cots. The labour suite is located on the same floor as B26 and has maternity operating theatres, 9 beds for women in labour plus 4 observation beds, and a bereavement suite. The induction suite is also based in the labour suite, as is the Sanctuary birth centre which is a 4 bedded midwife led unit. The triage unit is a standalone area with a 3 bedded triage room and a separate assessment room with 2 trolleys. The day assessment unit has 4 beds.
Community maternity services are provided by teams of midwives predominantly commissioned by NHS Nottingham and Nottinghamshire Integrated Care Board. They offer women a homebirth service and postnatal care. We did not inspect the community services during this inspection.
We inspected the service on the 25 and 26 April 2023. The inspection team comprised 2 inspectors and a midwife specialist advisor. An inspection manager oversaw the inspection.
We placed conditions on the provider’s registration following our inspection in October 2020. The provider was served a warning notice following our inspection in March 2022. During this inspection, the trust had met most of the requirements of the warning notice with the exception of electronic observation. We have served the provider a requirement notice to ensure improvements are made.
During our inspection we visited ward C29 (postnatal ward), B26 (antenatal ward), triage, the day assessment unit and the labour suite. We spoke with 32 staff including midwives, midwifery support workers, obstetricians, anaesthetists, managers, and reception staff. We reviewed 13 patient records and 12 patient prescription charts. We spoke with 6 women and 2 partners about their experience of the trust.
14 March 2019
Our rating of this service stayed the same. We rated it as good because:
- Clinical and operational staff used an effective system to ensure medical patients cared for as outliers on surgical wards received regular medical reviews and individualised care. This included multidisciplinary care and reviews from specialist teams such as allied health professionals and the rapid response psychiatry team.
- The safeguarding team were working with regional partners to standardise safeguarding training in line with new intercollegiate guidance. This would ensure local practice was benchmarked against national standards.
- The patient safety team had a key role in maintaining and improving safety standards, including through benchmarking and acting on local risks. The team used the human factors analysis and classification system as a tool during the root cause analysis of serious incidents to ensure they fully understood the actions and thought processes of staff.
- Multidisciplinary staff had introduced a range of initiatives to improve nutrition and hydration, including of older patients, in addition to standard use of the malnutrition universal scoring tool. This included a gold standard programme to ensure patients had access to nutritious food that was culturally appropriate and served during facilitated mealtimes to promote social contact.
- Professional development and education were clear priorities for medical care. Patient outcomes had demonstrably been improved as a result and staff were able to pursue more advanced qualifications and training.
- Multidisciplinary working was embedded in care services and a diverse range of specialist teams had established links with each other to address gaps in care provision and to improve patient outcomes and experience, including when patients transitioned to community care.
- The integrated discharge team worked across the hospital to improve access and flow through a more robust, patient-centred model of discharge planning and delivery. This was a multidisciplinary team that supported ward teams to establish more advanced understanding of discharges and had established a team of trained discharge coordinators.
- Staff routinely went above and beyond their responsibilities to provide additional care for patients that demonstrated the culture of compassion and kindness. This included setting up a clothes bank for patients with limited means to buy new clothes, fundraising for blankets for patients going home in the winter and liaising with the British Red Cross to support a patient at the end of their life.
- Specialist teams were increasingly aware of population-based health models and explored the needs and demographics of their target population to shape care and treatment, including health promotion interventions.
- A range of work had been completed to assess and improve accessibility to all elements of the service. This included improved access to mental health and drug and alcohol dependency care, language support and strict standards for information access. NHS England had certified the communications team as meeting The Information Standard, a national standard for health and social care information.
- The integrated discharge team and specialist services had developed discharge improvement projects based on the needs of their patients. The frailty service had experienced significant improvements, including a 5% increase in the pre-noon discharge rate and a 25% increase in use of the discharge lounge.
- Staff spoke positively of the trust’s vision and strategy and had adapted local variations to meet the trust’s objectives and reflect the needs of their patients. This included specialist teams not based on specific wards and reflected the enthusiasm of staff to deliver sustainable care.
- Governance processes and structures were well-established with clinical and operational oversight and assurance provided by a series of committees and multidisciplinary groups. Governance, risk and quality management processes demonstrably led to improved practice.
- The overall nurse vacancy rate was 19%, which reflected wide variations between specialties including one ward with a 50% vacancy rate.
- There was a lack of assurance around fire safety risk, including staff understanding of evacuation processes and training.
- From June 2017 to May 2018, patients at Queen's Medical Centre had a higher than expected risk of readmission for elective admissions and a higher than expected risk of readmission for non-elective admissions when compared to the England average.
- Some teams did not feel part of the broad improvements and innovative projects taking place in the hospital and did not feel they were valued by the trust or their colleagues.
14 March 2019
Our rating of this service stayed the same. We rated it as good because:
- Children’s and neonatal services had appropriate arrangements for investigating incidents and shared the learning from them.
- The services had a well- developed approach to assessing and responding to risk. Staff used a paediatric early warning system to take action on any deterioration in child health. There was a well-established and understood approach to managing and escalating suspected sepsis. Mental health risks were recognised and the service worked well with mental health professionals.
- People’s care and treatment was focused on achieving good outcomes, and this was supported by learning from clinical audit, and initiatives to improve clinical pathways.
- Parents and children told us that nurses and doctors were kind and took time to talk to them and explain care arrangements. The services did as much as possible to ensure that children were comfortable and they responded quickly if a child or young person was in pain. The services helped young children feel settled through play specialists and a variety of volunteers who entertained them, such as Spiderman, a magician, and a therapy dog.
- The services took a holistic approach to childhood and teenage cancer treatment and offered emotional support and arranged relevant social activities for them.
- Children generally had access to timely initial assessment, test results, diagnoses and treatment. Waiting list performance for the service was better than the national target of 92% of patients being definitively treated within 18 weeks (incomplete pathway). The cancer service was responsive and timely.
- Senior leadership capacity for children’s and neonatal services was improving and the leadership team was starting to address significant strategic risks and issues, for example how to ensure staffing and skills levels long term.
- Some beds on wards were not open to children because there were insufficient staff to manage them safely.
- Vacancy rates and turnover figures were high for doctors in neonatal services. The service was advertising for three new neonatologists to give the services some resilience across City and QMC sites in 2019.
- Outpatient appointments did not always run on time and the service did not inform families or display wait times publicly. The outpatient waiting area was very crowded.
- Not all services were available 24/7 and outpatient and day surgery appointments were predominantly during the week between 9am and 5pm.
- Lack of out of hours access to paediatric interventional radiology meant that some babies needed to be transferred to other hospitals, and this had been on the service’s risk register for three years.
- Arrangements for MRI scans 48 hour after tumour removal were not sufficiently formalised for children who needed a general anaesthetic.
- Children and young people’s matters did not have a strong profile at Board level and lacked specific non-executive director representation.
- Processes around monitoring that products were kept at a safe temperature in fridges were not robust.
14 March 2019
Our rating of this service improved. We rated it as good overall because:
- The trust had taken steps to improve consistency in completion of patient’s nutritional screening and the completion of nutrition and fluid charts.
- Improvements had been made to the availability of patient information leaflets, including those in other languages and accessible formats.
- Staff followed policies and procedures to ensure medicines were administered appropriately to make sure people are safe.
- The trust had implemented care plan documentation specific to end of life care.
- The Trust had increased their number of palliative care consultants to improve availability of a senior end of life care clinician.
- Do Not Attempt Cardio-Respiratory Resuscitation (DNACPR) forms were not always completed correctly.
- Conversations with patients and relatives regarding DNACPR decisions were not always documented in patients’ medical record.
- Mental Capacity Act assessments were not always completed for relevant patients when making DNACPR decisions.
- Care plans, although personalised and improved since last inspection, did not always document conversations about patient’s mental health needs, spiritual and pastoral needs.
- There was a lack of audit processes to monitor the effectiveness of end of life care.
- The service did not monitor or audit if end of life care patients died in their preferred place of death (PPD).
- The trust was not providing a HPCT seven days a week. However, this would commence in April 2019.
- The service did not record palliative or end of life care patients as delayed transfers of care
8 March 2016
Overall, we judged the outpatients and diagnostic imaging services to be good.
There were reliable processes to protect patients from avoidable harm. Departments were mostly clean and hygienic, and risks to patients attending appointments were monitored and well managed. Staffing levels were appropriate to the needs of each outpatient clinic, but there were unfilled vacancies in radiology which had an impact on the service. Patient records were not always well managed; paper files were overdue for collection and secure storage and patient letters were sometimes misfiled.
The care and treatment of patients was delivered in line with current evidence based practice and recognised national guidance. Staff had good opportunities for personal and professional development. There was effective multidisciplinary working in many departments. There were few seven day services. Staff supported patients in a caring, kind and compassionate way. They respected patients privacy and dignity, and made sure that people's individual needs were met.
Services were largely planned to meet people's needs. While the trust was able to provide timely assessments for people with non-urgent conditions, the trust did not meet national standards for urgent referrals. There were higher than average rates of cancelled appointments, both by hospital staff and patients. The hospital had put in place some innovative methods aimed at reducing cancellation and unattended appointments. There were largely effective governance structures, but not all risks were recorded and addressed. There was work in progress to re-design the outpatient pathway and improve the trust-wide outpatient service. Staff were committed to their roles and in most departments there was a positive, supportive working culture. There was good staff and public engagement, and a focus on continued improvement.