Queen's Medical Centre

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 undertook a focused inspection on three quality statements. We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration.

At our last inspection we rated this key question as requires improvement. At this assessment, the rating remained as requires improvement due to the focused nature of this inspection. This meant women were not always protected from avoidable harm.

The key question of safe was not assessed on this inspection and the rating is based on our previous assessments.

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.

During this inspection we only assessed limited aspects of this quality statement please see the previous report for a full assessment of the quality statement. The rating is based on our previous assessments.

The service had a proactive and positive culture of safety; however, this was not always based on openness and honesty. Staff listened to concerns about safety and investigated reported safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff knew what incidents to report and how to report them. Staff raised concerns and reported incidents and near misses in line with trust policy. Staff could describe what incidents were reportable and how to use the electronic reporting system. Staff did not report all events of aggression and violence from patients and their significant others as they were not assured action would be taken by the trust.

Staff had training from the police service about physical violence. It was unclear from staff or the supporting evidence provided if they had received training on de-escalation techniques or other strategies to manage the aggressive behaviours. The training involving the police had been hospital wide training, and it was unclear how many midwives had attended this training.

Despite a situation being dealt with and reported the previous morning by the midwifery team, they received no senior support until the afternoon. The agency nurse dealt with the situation and was able to protect patients and the staff through her insistence with the security team on the removal of the antagonist.

We also heard that an incident that occurred on C29 that was the result of a lack of reclining chairs for partners to sleep on. Staff told us that this meant that some partners slept on the floor. However, the trust informed us that there had only been one incident of this being reported. Staff recognised the relationship between tired and frustrated partners and aggressive incidents.

The service had introduced a system of core and rotational working. This meant that whilst some midwives stayed in an area others rotated throughout the department. Whilst some midwives liked the idea of maintaining their skills in all areas, others felt that they had already lost some skills having worked in a defined area for a considerable time. The trust recruited core staff who were able to provide clinical expertise to support rotational midwives. This was an ongoing process.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

During this inspection we only assessed limited aspects of this quality statement please see the previous report for a full assessment of the quality statement. The rating is based on our previous assessments.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. Staff concentrated on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. We saw evidence that baby abduction drills were completed but staff on duty were unable to corroborate this. Security tags were not available for every baby and were not securely applied when used.

We spoke with 12 members of staff who could not remember when the last baby abduction drill had occurred. When asked what would happen if the baby alarm sounded they stated that they would check the linen first as often tags would be thrown out with linen. Baby alarms were secured using a nappy pin onto the clothing of the baby. This meant that they were easy to remove. The baby alarm would sometimes trigger as being out of range if the mother and baby had been placed in a bed space on the final wall of the postnatal ward. Alarms were often found on windowsills or bed tables as when mothers changed baby’s clothing they forgot to move the alarm onto the new clothing. This meant that babies may not be protected from abduction. Staff stated that they had used more robust systems in previous organisations.

Whilst doors were opened via call systems the closures on the doors were delayed, due to them also being fire doors. We attempted to shut a door after we had passed through it and was told that this would automatically close. It took several minutes for this to occur. We saw evidence that staff had been reminded to be aware of people tailgating through the doors. The door from the postnatal ward was beside the nurses station. However, we witnessed people being buzzed out without staff really looking at the person

Ward staff could give examples of how to protect women from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff understood the importance of supporting equality and diversity and ensuring care and treatment was provided in accordance with the Act.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

During this inspection we only assessed limited aspects of this quality statement please see the previous report for a full assessment of the quality statement. The rating is based on our previous assessments.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. We saw that there were safe systems for the storage of medicines. Out of date medicines had been removed and that there was a daily pharmacist visiting the areas. Stock levels were much reduced. A new clinical room was being installed on B26.

The procedure for the storage of breastmilk had begun to improve. Women were responsible for storage, labelling and collecting their own breast milk. There was a list of questions for the daily audit of the breast milk fridge. This had been commenced late January 2026 and there were no monthly audits available at the time of our inspection. The only freezer for breast milk expressed in advance of labour was on the labour suite.