Conquest Hospital

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that people and communities were always at the centre of how care was planned and delivered. We checked that the health and care needs of people and communities were understood, and they were actively involved in planning care that met these needs. We also looked for evidence that people could access care in ways that met their personal circumstances and protected equality characteristics 

We assessed all quality statements in this key question. 

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people’s needs were not always met. patient flow within the hospital affected timely access to ongoing care and treatment. 

People experienced delays in admission to specialty wards and inconsistent access to mental health assessments, particularly children and young people. Sustained overcrowding limited staff’s ability to consistently make reasonable adjustments and affected privacy, dignity, access to appropriate care environments, and timely access to food, medicines, and specialist support

However, staff worked hard to respond to people’s needs in challenging circumstances. Effective assessment and streaming processes supported prompt ambulance handovers, helping patients access care more quickly and enabling ambulance crews to return to serve the community.

The service had access to community pathways such as virtual wards and frailty services which helped meet people’s needs and reduce avoidable hospital admissions.

We have not awarded this service a score for Responsive.

Find out about when we will not publish a key question score and what we look at when we assess Responsive.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people were at the centre of their care and treatment choices, and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

The service did not consistently make reasonable adjustments to support people to access care. Staff made sustained efforts to put adjustments in place, but overcrowding often prevented them from doing so. 

The service had not ensured equipment to support patients with hearing impairments was available and functioning as intended. The service did not have functioning hearing loops for people with hearing impairments. A hearing loop delivers sound from a source, such as a microphone, directly to a user’s hearing aids. Leaders told us an induction hearing loop should have been available at the reception area. However, they became aware following our assessment that the system had not been working for an extended period. They told us a repair request had subsequently been submitted. This meant patients who relied on the hearing loop may have experienced barriers to communication, potentially affecting their ability to access information and engage fully in their care and treatment. They did not provide a timeline of when this would be functional again. 

The service did not consistently use available specialist support to meet the needs of patients living with dementia. Staff used the electronic patient record to identify patients living with dementia. However, members of the dementia team told us they were not routinely asked to support patients in the emergency department because patients were generally expected to have a short stay. Dementia team staff also told us a dementia resource box was available in the department, but staff we spoke with were unaware of its existence. This meant patients living with dementia may not have consistently benefited from specialist support, resources or interventions designed to reduce distress and improve their experience of care.

However, most patients we spoke with told us staff placed them at the centre of their care and treatment. Patients reported feeling involved in care planning and shared decision-making. Results from the Urgent and emergency care survey 2024, showed the hospital scored similarly to other trusts for involvement in decisions about care and treatment.

Staff generally considered patients’ individual needs and preferences. Staff we spoke with understood the importance of undertaking risk assessments, how to complete them, and who to contact for support.

The service triaged patients with mental health needs in the emergency department before referral to specialist services. A mental health quality improvement project had resulted in the appointment of a dedicated mental health workforce within the department, including mental health support workers and registered mental health nurses. This improved access to specialist mental health support, enabled earlier identification and management of mental health needs, and helped staff provide more coordinated care while patients awaited assessment or onward referral.

Staff encouraged patients to use a hospital passport to inform staff about the needs of people with a learning disability and how best to support them.

Staff provided patients with food, blankets, pressure‑relieving equipment and additional pillows to support comfort while waiting for care.

The service provided a multi‑faith room, with chaplaincy staff available to attend patients at the bedside on request.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Leaders described how the communities they served had diverse health and care needs. They followed established processes to support joined‑up care and treatment without disadvantaging patients. Staff told us that measures were in place to support people with mental health conditions, learning disabilities and people who were autistic. and they could access specialist advice and support learning disability and dementia nurses, as well as the psychiatric liaison service provided by an external organisation.

The trust worked in partnership with external organisations to develop and improve services for people within their local communities and to promote equitable access and outcomes. The trust implemented a virtual ward model to support frail people who were well enough to return home, enabling discharge from hospital with appropriate community-based support. 

We reviewed service development plans that outlined work to improve pathways between acute and out‑of‑hospital services. These plans aimed to reduce the conveyance of frail patients to hospital and prevent avoidable admissions where care could be more appropriately and safely delivered at home.

However, the paediatric emergency department did not consistently meet the needs of children and young people experiencing mental ill health. Mental health assessments were provided by an external provider and delays in assessment increased the risk of young people becoming distressed, absconding from the department or posing a risk to themselves or others while waiting for support.

Leaders could not demonstrate effective oversight of delays affecting paediatric patients awaiting mental health assessment. The service did not provide data on the length of time children and young people waited for mental health review. 

The service maintained a tracker of patients experiencing mental ill health who left the department before their care was complete, including paediatric patients. However, it was unclear when data collection had commenced, with the earliest recorded entry dated September 2025. The tracker recorded actions taken by staff in response to individual incidents, demonstrating some attempts to manage risks associated with patients leaving the department.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff knew how to make notifications to external bodies such as the local authority for safeguarding concerns. Information governance arrangements supported the confidentiality of patient records. The service complied with the accessible information standard (AIS), and the trust’s patient information policy set out clear guidance on producing information.

Patients could expect information to be tailored to their individual needs, including reasonable adjustments for disabled people and access to interpreting and translation services.

Patient information leaflets were available on the trust website and could be accessed by using QR codes. Some information was available in large print, easy read format and different languages. The service provided patients with a range of discharge information including contact details of external agencies. Posters describing staff uniforms and their roles were displayed in waiting areas.

Staff had access to information governance, data protection, and equality and diversity policies on the intranet. Staff could also seek advice from the trust Caldicott Guardian. A Caldicott Guardian is a senior person responsible for protecting the confidentiality and appropriate use of people's health and care information.

The service sent discharge letters electronically to GPs and other professionals where required, such as for example community nursing. Staff stored patient paper records securely.

Patients were not always kept informed about the progress of their care and treatment. Most patients we spoke with said staff explained their treatment plan and what they were waiting for next. The CQC Urgent and emergency care survey 2024 showed the trust scored similarly to other trusts for and the time spent waiting. However, some patients were unclear about the next steps in their care after being seen by a healthcare professional. For example, we spoke with a patient in a super-surge area who did not know what they were waiting for. We later established that they were awaiting transfer to an inpatient ward bed. This meant patients did not always have sufficient information about their onward care, which could increase uncertainty and anxiety while waiting for treatment or admission.

People were not consistently provided with information about expected waiting times. The department had an electronic information screen in 1 waiting area; however, this was not visible from other waiting areas. All people we spoke with said they had not been told how long they were likely to wait when they arrived. As a result, people were not always able to understand delays in their care, which may have caused unnecessary anxiety and uncertainty.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

The service made it easy for people to share feedback and ideas. Staff assisted patients to raise concerns. Patients, carers and relatives could make complaints directly through the trust’s patient advice and liaison service (PALS). They could also make a complaint through the trust’s website by telephone, online form or email.

The emergency department received 41 complaints from 1 March 2025 to 28 February 2026. The main themes related to admission and discharges, clinical treatment, including delays in diagnosis or treatment, patient care and staff values and behaviours. A Lead Nurse and Consultant acted as named leads for complaints, reviewing each complaint and determining the most appropriate course of action. It was clear who was responsible for responding to complaints, with designated leads identified for each case. The service discussed complaints at clinical governance meetings, and themes were fed into nursing education days to support learning and improvement. 

Staff took complaints seriously and used them to improve care and treatment where possible. Staff knew how to manage complaints appropriately and offered telephone calls and local resolution meetings with patients, relatives and carers. We reviewed examples of complaint handling, which showed clear ownership of concerns, appropriate actions taken in response, and apologies offered where required.  

The service used a red, amber, green (RAG) rating system to monitor complaints response time and progress through stages of completion. For example, a 3-weekly complaint report showed 3 complaints were rated red or amber for breaching the trust’s 60-day response target.

Staff we spoke with told us they received feedback on the outcome of investigations and recognised complaints as opportunities for learning and improving the service for patients. 

Patients knew how to make a complaint or raise concerns, and the service clearly displayed information about how to do so. Managers investigated complaints, identified themes and shared feedback and learning with staff. Staff understood the complaints policy and were able to describe how learning from complaints was used to improve the service.

We scored the service as 1. The evidence showed significant shortfalls.  The service did not make sure that people could access the care, support and treatment they needed when they needed it. 

The service did not provide care and treatment in a timely way. Hospital-wide pressures continued to affect patient flow and leaders did not take effective action to reduce the impact of delays within the emergency department. Data showed the proportion of patients spending more than 12 hours in the department had increased since January 2023.

In December 2025, 9.2% of patients attending the emergency department waited more than 12 hours. Staff only recorded decisions to admit following review by a senior specialty clinician. This meant the decision to admit may not have been recorded at the point it was first made, resulting in reported performance data that may have underestimated the number of patients who experienced waits of more than 12 hours. Although leaders told us they monitored patients' total length of stay within the department, they did not provide this data during the inspection. As a result, leaders could not accurately demonstrate the extent of delays or show how they used this information to drive improvement.

Leaders did not effectively mitigate the risks associated with overcrowding. Although staff followed escalation policies when caring for patients in temporary escalation areas, patients continued to receive care in environments that were not designed for clinical treatment and did not support privacy and dignity. This increased risks to patient safety and negatively affected patients' experience of care.

Children and young people experienced delays in accessing mental health support. Leaders told us these delays reflected national pressures; however, the service did not provide a dedicated safe space for children and young people experiencing a mental health crisis while waiting for assessment. As a result, some children and young people waited for prolonged periods in environments that did not meet their emotional, psychological or safety needs. This increased the risk of distress and deterioration and negatively affected their experience of care.

The service's mental health tracker showed that 54 patients experiencing mental ill health left the department before receiving an initial assessment. This meant some patients left before staff assessed their needs or arranged appropriate support. As a result, patients may not have received timely treatment, intervention or referral, increasing the risk of deterioration, self-harm or harm to others. The number of patients leaving before assessment also indicated that delays and environmental factors affected patients' ability to remain in the department while waiting for care. Leaders did not demonstrate how they used this information to identify themes, understand underlying causes or implement effective actions to reduce recurrence.

Despite these concerns, the service performed well in some areas. Leaders ensured the department had adequate medical cover throughout the day and night, and doctors responded promptly during emergencies. Staff described positive working relationships with medical teams and told us they could access support from the acute medical unit when required.

Leaders monitored performance against national standards and targets. The service performed well against the national average for ambulance handover times. During the inspection, we observed a nurse and doctor at the rapid treatment and assessment area who assessed patients promptly and directed them to the most appropriate area of the department. This reduced delays for ambulance crews and supported their timely return to the community.

Data showed ambulance handover times remained below 17 minutes between December 2025 and February 2026. The average wait for triage following ambulance arrival was 14 minutes during the same period. Patients and relatives also spoke positively about the timeliness of initial assessment. One relative said their child was seen immediately on arrival and praised the new paediatric area for helping to make "children more comfortable".

The department was fully accessible for people with disabilities and wheelchair users.

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The provider used equality impact assessments to review policies and ensure vulnerable people and those with protected characteristics were not placed at a disadvantage. The trust’s equalities and human rights impact assessment guided staff in identifying and addressing potential risks for groups with protected characteristics. The equality, diversity and inclusion policy supported the delivery of a fair, diverse and inclusive workplace and healthcare service.

All staff completed equality, diversity and human rights training as part of their mandatory training. Compliance for all staff groups was 94%, which was above the trust target. 

The service had processes to support staff to deliver care and treatment without disadvantaging people with protected characteristics. Staff told us there were measures to support people living with mental health conditions, learning disabilities, autism, and dementia, to receive care that met their needs. Staff could access advice and support from specialist nursing teams, such as learning disability nurses, dementia nurses and the psychiatric liaison service provided by a system partner. However, staff told us they seldom used the dementia team. 

Leaders recognised the barriers faced by people with poor mental health when accessing emergency care and had implemented a dedicated mental health team within the department. This included clinical support workers and registered mental health nurses to support patients while in the emergency department.

Service leaders also recognised the increase in the number of frail older people accessing services locally. Staff demonstrated an awareness of these pressures, and the trust had frailty services, including an in‑reach frailty service within the emergency department. We saw that service development discussions and future planning focused on delivering timely, responsive and equitable care for vulnerable patients, including those living with frailty. 

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Specialist nurses were available to promote patients’ independence and provide ongoing support. The service also operated virtual wards to support people at home. Virtual wards (also known as hospital at home) enabled patients to receive the care they needed safely and conveniently in their own homes, rather than in hospital.

Our review of a sample of patient care records showed that documentation was generally completed in enough detail. Records included information about mental and physical health needs, safeguarding checks, falls risk assessments, diagnoses, and management plans. Staff developed care plans that reflected needs identified during assessment.

The service followed the trust’s established processes for recording and storing living wills and advance directives. These documents clearly set out individuals’ preferences regarding future medical treatment. The trusts end of life care policies reflected national guidance, and compliance was monitored by annual audits.  

The service had a dedicated bereavement room within the footprint of the emergency department, as well as a dedicated family room, to support patients and relatives at difficult times.