Queen Elizabeth Hospital

Updated 24 January 2024

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 4 the ratings and information relate to maternity services based at Queen Elizabeth Hospital.

We inspected the maternity service at 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.

Queen Elizabeth Hospital provides maternity care and treatment to women, birthing people and babies from Woolwich and surrounding areas, as well as providing support to University Hospital Lewisham and working with other trusts from the Local Maternity and Neonatal System (LMNS). The LMNS covers Southeast London. Staff at the hospital delivered 4,181 babies between July 2022 and June 2023.

Maternity services at Queen Elizabeth Hospital includes an obstetric consultant-led delivery suite, maternity assessment unit (triage) and wards for antenatal and postnatal care. A midwife-led birth centre provides intrapartum care for women and birthing people who meet the criteria and are assessed to have lower risk pregnancies.

We last carried out a comprehensive inspection of the maternity service in September 2018.

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.

We did not review the rating of the location, therefore our rating of this hospital stayed the same Queen Elizabeth Hospital is rated requires improvement.

We also inspected one other maternity service run by Lewisham and Greenwich NHS Trust. Our reports are here:

University Hospital Lewisham - https://www.cqc.org.uk/location/RJ224

How we carried out the inspection

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

We visited maternity assessment (triage and the day assessment unit), labour ward, the midwife-led birthing centre, the antenatal and postnatal wards.

We spoke with 3 women and birthing people and 3 birthing partners and or relatives. We also spoke with 19 midwives, 2 support workers, 4 doctors, 2 student midwives and 3 other staff. We received no responses to our give feedback on care posters which were in place during the inspection.

We reviewed 6 patient care records, 6 Observation and escalation charts and 6 medicines records.

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 3 July 2020

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

• The service had enough nursing staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed staffing levels and skill mix, and gave bank and agency staff a full induction.
• Since our last inspection the trust had clearly benefitted from adopting electronic patient records and prescribing systems. These had improved the way the trust collected, analysed, managed and used information to support all its activities.
• The service managed patient safety incidents well. Staff recognised incidents and near misses and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team. When things went wrong, staff apologised and gave patients honest information and suitable support.
• We saw all grades of staff treat people with dignity, respect and kindness during their stay on the wards. Staff were seen to be considerate and empathetic towards patients. Most of the patients we spoke with were positive about the staff that provided their care and treatment.
• There was openness and transparency among all grades of staff and staff spoke positively about their line manager.
• The service provided care and treatment based on national guidance and best practice. Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients.
• Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary.
• The service took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
• People could access the service when they needed it and received the right care promptly.
• The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
• Staff spoke in positive terms about the visibility of the new senior management team and the triumvirate model. Many commented that “things had really improved” over the last two years.
• Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills.
• The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. Leaders and staff understood then and monitored progress.
• Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact.

However,

• We found breaches of the regulations in the way medicines were stored. The breaches we identified in medicines management and storage were shared with the division by inspectors and these were addressed immediately during the inspection. We saw these aspects had also improved when we returned for an unannounced visit.
• Mandatory training in safeguarding and key skills for nursing and medical staff completion rates remained below the trust target of 90%.
• The trust supplied data demonstrating that vacancy rates for medicine had been reduced from 21.1% in April 2019 to 13.9% in Feb 2020. These figures were comparable with other core services although when we visited we found the division continued to rely on bank and agency or locum staff to cover gaps in staffing provision.

• During our unannounced visit, the out of hours staffing levels of doctors were less than planned.

• While we acknowledge clear improvements in leadership and governance, aspects such as the poor medicine management and ongoing issues with mandatory training indicated that aspects of governance needed further development.

Updated 3 July 2020

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

• Some of the concerns found at the 2017 inspection had still not yet been addressed. During our previous report in March 2017 we found there was a lack of consultant representation at governance meetings. During this inspection we found there was still a lack of consultant attendance at some governance meetings.
• Nursing and medical staff did not meet the trust’s training standard for all life support training modules staff were eligible to complete.
• Mandatory training for medical staff did not meet the trust’s key performance indicators (KPI).
• Although most nursing staff received and kept up-to-date with their mandatory training, some mandatory training modules did not meet the trust’s key performance indicators.
• There was a lack of tailgating notices at access points to children’s wards.
• The low number of records reviewed during records audits meant there was a risk of records audits not being sufficiently representative.
• The numbers of staff receiving an appraisal did not meet the trust’s key performance indicator (KPI).
• Medical staff training rates in the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards did not meet the trust’s KPI.
• The trust’s KPI was not being met for average length of stay,
• The trust’s KPI was not being met for the number of children discharged before 12 noon,
• The trust’s KPI was not being met for electronic discharge summaries being sent to patients GPs within 24 hours,
• The trust’s KPI was not being met for the percentage of complaints responded to within agreed timescales.
• Although there had been a reduction in the numbers of children transferred from Hippo ward to paediatric ED due to the closing time of Hippo ward. From January to December 2019, 65 children had been transferred between the wards due to the ward closing time.
• The service did not have documented local vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders.
• Processes for monitoring service quality and improvement were not always consistent.

However:

• All staff we spoke to were aware of their responsibilities relating to duty of candour under the Health and Social Care Act (Regulated Activities Regulations) 2014.
• Care was being provided in accordance with the national quality standards and best practice guidelines. Most guidance and policies within children and young people’s services had been reviewed and were based upon current guidance.
• Staff treated children, young people and their families with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
• The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care.
• The service was inclusive and took account of children, young people and their family’s individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
• Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.
• Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.

Updated 3 July 2020

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

• The service had taken action to address concerns raised following our last inspection. Our ratings for safe and responsive improved from requires improvement to good. We rated well led as outstanding as we found leadership, culture and staff engagement within the service were exceptional. Leaders recognised that promoting staff wellbeing, and supporting staff engagement, were key in delivering high-quality, patient-centred care.
• The service had enough staff to care for patients and keep them safe. 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, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• 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. 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 and the community to plan and manage services and all staff were committed to improving services continually.

Updated 11 January 2019

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

• There was still not a seven-day SPCT service.
• The often-large paper patient medical records were not always fully bound or in the correct order.
• We noted inconsistent completion of mental capacity assessments, the recording of pain scores and eating and fluid intake charts.
• There was no succession planning for when the current end of life care strategy comes to an end in March 2019.
• Minutes from the end of life steering group showed that attendance was variable.

However:

• Awareness of end of life care at staff and trust level had improved since our previous inspection.
• There was evidence of good multidisciplinary team working between ward staff, the specialist palliative care team (SPCT) and other allied healthcare professionals (AHP).
• A dedicated end of life risk register had been introduced since our last inspection.
• With the help of the SPCT rapid discharge of patients to their homes or other preferred place of care could be arranged.

Updated 24 January 2024

Updated 17 August 2017

Outpatients and diagnostic imaging were rated as good because patients were receiving safe, effective care and the service was well-led. The service needed to improve how it responded to patients.

We found a good culture of reporting incidents and the environment was safe and clean. Equipment had been cleaned and checked. Care and treatment was provided in line with national guidance and regulations. Patients told us staff were kind and said they felt involved in their care with staff providing explanations as needed.

Staff were positive were about their immediate managers and said they supported them and they felt valued. Outpatients and diagnostic imaging had developed a five year strategy for improving the service

However, the service was not always meeting national referral to treatment times and the ‘Did not attend’ (DNA) rate was higher than the England average. Many of the clinics were observed were running late and there was no evidence that this was being monitored.

Updated 3 July 2020

Our rating of this service improved. We rated it as good

• Following our inspection in 2018, there had been improvements to the surgical service. Staff were overwhelmingly positive about the divisional and local leadership for the service. In contrast to our findings during our last inspection, all staff groups felt they provided positive leadership, strong direction and supported staff.
• Staff confirmed there had been a positive culture change in the last two years. This led to better staff retention, in particular, medical staff.
• Governance process was robust and risks were regularly reviewed and updated. Staff were engaged in the governance agenda and quality improvement project.
• There were effective systems in place to protect patients from harm and a good incident reporting culture. Staff informed us they reported all incidents. This was in contrast to findings during our last inspection when low level incidents were not always reported
• Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and relevant risk assessments were completed.
• Patients received effective, evidence-based care from staff who were appropriately qualified to care for them. The service monitored the effectiveness of care and treatment and patient outcomes were within expected standards.
• Feedback for the services inspected were mostly positive. Staff respected confidentiality, dignity and privacy of patients.
• Services were developed to meet the needs of patients. The service had a surgical assessment unit for rapid assessment and treatment of patients. There were dedicated surgical wards for different specialities and good patient flow across surgical services.

However,

• The service was not meeting the trust target for mandatory training and staff appraisals.
• Although medicines management had improved since the last inspection, we still identified some areas of concern. This was reflected in the trust medicine audits which showed compliance was sometimes below trust standards.
• Although patient flow had improved since our last inspection, the day care unit was no longer ringfenced due to wider bed pressures in the trust. This increased the risk of cancellations for elective surgeries due to inpatient admissions.
• Action plans for national audits were not always comprehensive. Most action plans did not identify a course of action in line with the recommendations made and there were no timescales for completion.

Updated 3 July 2020

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

• The escalation corridor was still being used to manage ED patients although this was significantly less than during our previous inspection in September 2018.
• We found that rooms and areas for mental health patients presented risks for self harm despite risk assessments and first stage mitigation being completed for these areas.
• We found that risk assessments of mental health patients were not always comprehensive or up to date. These were recorded on several systems that did not share information. This meant staff could not always access patients risk assessments or management plans in a timely way.
• Records for mental health patients who required multidisciplinary interventions were inconsistent and lacking critical information for the safe care of patients.
• Medical staffing levels did not meet the Royal College of Emergency Medicine or Royal College of Paediatrics and Child Health guidelines for safer staffing in ED. This was reflected in the lack of 16 hour consultant cover and also that the paediatric ED did not have a paediatric emergency consultant with dedicated session time allocated to QEH.
• The friends and family test was below national average and response rates were low which indicated that a significant proportion of patients were not satisfied with their care
• People could not always access the service when they needed it. Waiting times for patients to be admitted, transferred or discharged were not in line with good practice. For example, from December 2018 to November 2019 the trust failed to meet the four hour standard and performed worse than the England average from February 2019 to August 2019. However, from August 2019 to November 2019 the trust performed in line with the England average.
• Mental health governance processes were not yet fully implemented or where at early development stages at the time of inspection.

However:

• The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean
• The service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
• The service provided care and treatment based on national guidance. There was a strategy to monitoring local activity through internal auditing.
• 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 development.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
• Staff provided emotional support to patients, families and carers to minimise their distress.
• The service provided care in a way that met the needs of local people and the communities served.
• Ambulance handover times showed signs of improvement and greater compliance with the 15 minute handover time since our last inspection. We saw evidence that a key ambulance stakeholder praised the service for their 12 month average being under 13 minutes and the positive impact it had on patient care.
• Staff felt respected, supported and valued. They were focused on the needs of patients receiving care.
• The service had a clear vision and strategy to what it wanted to achieve. Leaders, staff and the executive team were all working towards the same direction.
• Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. Staff contributed to decision-making to help avoid financial pressures compromising the quality of care.