The Queen Elizabeth Hospital

Updated 1 March 2024

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at The Queen Elizabeth Hospital.

We inspected the maternity service at The Queen Elizabeth Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

The Queen Elizabeth Hospital provides maternity services to the population of west Norfolk, north Cambridgeshire and south Lincolnshire.

Maternity services include a maternal and fetal medicine, outpatient department, maternity assessment unit, combined antenatal and postnatal ward (Brancaster), central delivery suite / labour ward, midwifery led birthing centre (Waterlily), and two maternity theatres. Between April 2022 and January 2023, there were 1598 babies born at The Queen Elizabeth Hospital.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

Our rating of this hospital stayed the same. We rated it as Requires Improvement because:

Our rating of Good for maternity services did not change ratings for the hospital overall. We rated safe as Requires Improvement and well-led as Good.

How we carried out the inspection

We provided the service with 2 working days’ notice of our inspection.

We visited maternity assessment unit, maternity triage, delivery suite, the antenatal and postnatal ward and the antenatal clinic. We spoke with 22 people including the interim head of midwifery, an obstetrician, 3 doctors, an anaesthetic consultant, 13 midwives and two women and their families. We attended handover meetings and reviewed records.

We received 90 responses to our give feedback on care posters which were in place during the inspection.

Feedback received indicated 55% of women and birthing people had mostly positive views about their experience, although 45% had mixed or negative views. Feedback included concerns about communication, staffing numbers and support needed following birth.

Following our onsite inspection, we spoke with senior leaders within the service. We also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 23 February 2022

Updated 24 July 2019

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

• The service provided mandatory training in key skills. Nursing staff mandatory training compliance was 90% on Rudham ward and 91% on NICU. Staff had safeguarding training and they knew how to recognise, and report abuse to protect patients.
• The service had suitable premises and equipment, looked after them and controlled infection risk well.
• Staff kept detailed records of patients’ care and treatment, completed and updated risk assessments for each patient and followed best practice when prescribing, giving, recording and storing medicines. Care and treatment was based on national guidance.
• The service had enough nursing and medical staff with the right qualifications, skills, training and experience to keep people safe from harm and to provide the right care and treatment. Managers made sure staff were competent for their roles, appraised staff’s work and performance. Staff of different specialities worked together as a team to benefit patients.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
• Staff gave patients enough food and drink to meet their needs and improve their health. They assessed and monitored patients regularly to see if they were in pain and promoted good health.
• Staff understood how and when to assess whether a patient had the capacity to make decisions about their care and understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff cared for patients with compassion, provided emotional support and involved patients and those close to them in decisions about their care.
• The trust planned and provided services in a way that met the needs of local people and took account of patients’ individual needs. Waiting times from referral to treatment were in line with good practice.
• Managers at all levels in the service had the right skills and abilities to run a service providing care and they promoted a positive culture that supported and valued staff.
• The service had effective systems for identifying risks, collected, analysed, managed and used information well to support its activities and engaged with patients and staff to plan and manage appropriate services. The service treated concerns and complaints seriously.

However:

• Mandatory training compliance for medical staff did not meet trust target (90%) for any of the eight modules.
• Safeguarding children level three training compliance for nursing and medical staff did not meet trust target of 95%. Nursing was 89% and medical staff was 85%.
• The service did not have enough consultants to meet royal college of paediatric and child health (RCPCH) guidance and consultant handwriting was not always legible in all medical records.
• Not all nursing staff in NICU handed over care of the babies when leaving the nursery for an extended period of time and one member of nursing staff was heard to use discriminatory language when speaking about a patient with known mental health issues.
• Staff on Rudham ward did not have a portable telephone call so that they could make confidential calls in a private area away from the nurse’s station.
• Governance structures were not embedded, not robust and did not give enough consideration to children and young people’s services and did not monitor the progress of the CYP strategy which staff were unaware of.
• There was no representation of CYP services at the quality and safety committee meetings, mortality review meetings or the mental health governance committee meetings and the service did not have a CYP specific learning disability nurse.

Updated 23 February 2022

Updated 16 December 2020

Our rating of this service improved. We rated it as requires improvement because:

• Staff mandatory and safeguarding training compliance did not meet the trust target. The service did not have enough substantive staff with the right qualifications and skills to cover all shifts. We were not assured that the out of hours staffing arrangement was sustainable and robust to provide safe care and treatment to patients. Staff did not routinely remove aprons and gloves when leaving a clinical area. Staff did not report all incidents that might impact the service or patient safety.
• Although effective governance processes and risk management systems were in place these were not fully embedded. Leaders acknowledged that there was further work required to engage effectively with all staff groups. Leaders in the service had a vision for what it wanted to achieve but this was not formalised in a vision and strategy.

However:

• Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients and acted on them. They managed medicines well. The service managed safety incidents well and learned lessons from them.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Most staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients to plan and manage services and all staff were committed to improving services continually.

Updated 24 July 2019

We rated the service as requires improvement because:

• Staff did not always complete mandatory training in line with the trust’s target. The trust target was not met for any of the seven mandatory training modules for qualified nursing and midwifery staff in gynaecology. The module manual handling had the lowest compliance rate of 33% below the trust target of 95%.
• Medical staff had not completed any mandatory training modules in line with the trust’s target. The trust target was not met for any of the eight mandatory training modules for medical staff in gynaecology. The module adult basic life support had the lowest completion rate of 52% which did not meet the trust target of 95%.
• The service utilised a high number of locum medical staff and we were not assured that all staff had the appropriate training. The trust was unable to confirm that all medical staff had the relevant ultrasound scanning competency.
• Not all nurses had the appropriate competencies in place to provide the right care and treatment. Nurses did not hold a recognised post qualification gynaecological course. Whilst competencies were in place the assessor had not completed their own competencies. However, there was access to clinical nurse specialists and midwives for advice and support.
• The service did not routinely audit the effectiveness of care and treatment and use the findings to improve them. The service did not participate in Royal College of Gynaecology Safer Standards national audits.
• People could not always access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with good practice.
• The timeliness of complaint responses did not meet local policy targets. Although the service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
• Leaders of the service did not always act on concerns raised in a timely manner. Staff did not feel empowered to improve the quality of care. Staff felt that they would escalate concerns, but no action would be taken.

However:

• There were systems and processes in place to monitor standards of cleanliness and hygiene. These included up to date policies, cleaning schedules and checklists, infection prevention and control training.
• There were systems and processes in place for medicine management concerning handling, storage and security of medicines. Staff kept medicines securely in the clinical areas we visited.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. The service took account of patients’ needs.

Updated 16 December 2020

Our rating of this service improved. We rated it as Requires Improvement because:

• Palliative care consultant staffing continued to be a concern but recognised as a nationwide problem. To mitigate any risks there was a clear demonstration of increased ownership for end of life care throughout the trust and clear recognition for the need for palliative care expertise. Consultant staffing from other local trusts were in place and we were assured they were accessible and provided support to care for patients in receipt of end of life care.
• Patient care records had gaps in the completion of Mental Capacity Act documentation. This was recognised by the trust and an ongoing piece of improvement work was being carried out.
• Patients did not always receive timely care or treatment in line with their wishes.

However:

• The trust worked collaboratively across the local health economy to introduce a new, sustainable end of life care strategy and address concerns raised at the previous inspection.
• The strategy was widely shared, and staff were engaged in the process of embedding the practical elements to ensure good quality end of life care.
• There was an executive lead, senior leadership team and clinical ownership and accountability across the trust for end of life care.
• Patient care records receiving palliative and end of life care contained Recommended Summary Plan and Emergency care Treatment (ReSPECT) documentation with do not attempt cardiopulmonary resuscitation (DNACPR) documented. Staff carried out audits to help ensure good quality completion and compliance.

Updated 1 March 2024

Updated 24 July 2019

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

• Although the service had suitable premises and equipment in most areas and looked after them well some areas did not meet the needs of the service. For example, the diabetic clinic consulting room. This impacted on staff being able to protect patient’ privacy and dignity when delivering care.
• Outpatient areas did not routinely audit the effectiveness of care and treatment and use the findings to improve them. This had not improved since the previous inspection.
• Non-admitted referral to treatment pathway rates were below the trust’s operational standard and the England average. This meant that patients were waiting longer for appointments after being referred by their GP.
• The trust did not routinely collect data on late starting clinics or patient waits in outpatients. Main outpatients had begun to collect this data but had yet to analyse the information collected.
• Car parking facilities did not always meet demand. Patients reported that they often had difficulty parking when attending for clinic appointments which caused them to be concerned that they would miss their appointment.
• The outpatient’s department did not have a local vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
• We were not assured that local risk and performance was monitored appropriately. There was a lack of robust monitoring of referral to treatment times and control audits across all areas of outpatients.
• The trust did not have processes in place to engage with patients, the general public and local organisations to plan and manage appropriate services. Staff were positive about engagement with local mangers but reported that engagement with the trust senior executive team was inconsistent.
• There were processes and systems of accountability within clinical business units although these were not always effective. Outpatients were split over a number of different business units. There did not appear to be oversight and shared learning across all outpatient areas.

However:

• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
• The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
• The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those 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.
• The service took account of patients’ individual needs.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. The average time to investigate and close complaints was **. This had improved since the previous inspection
• The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
• Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

Updated 16 December 2020

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

• Leaders and teams used systems to manage performance, however, performance was below targets.
• Staff mandatory training compliance and medical staff compliance with mandatory safeguarding training was below the trust target. This was as a result of changes to training due to COVID- 19, however, there were plans in place to improve compliance.

However, we also found;

• There were processes in place to ensure patients were safe when being admitted to hospital for surgical procedures. Staff completed training in mandatory and specialist skills to meet the needs of patients and there were safe numbers of staff working to meet care for patients. Staff used risk assessments to identify any risks and escalated them accordingly. The environment was suitable to meet the demands of the service, equipment was well maintained, and all areas appeared to be clean and tidy. Patient records reflected care that had been given or planned, and they were stored securely. Medicines were managed in line with guidance and administered in a timely manner. Staff were aware of their roles and responsibilities for reporting and managing incidents and teams shared learning.
• The surgery service leadership team had plans in place to manage activity and included staff in the planning and implementation of service changes. Leads were visible and easily accessible and well thought of by the wider team. There were robust governance processes underpinning activity and staff regularly reviewed performance, challenged findings and held each other to account. Risks were known and mitigation implemented to manage risks effectively. There was largely a positive culture, and staff were proud of their achievements.

Updated 23 February 2022