All inspections: Queen's Medical Centre

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.

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. 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 two 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 four observation beds, and a bereavement suite. The triage and induction suite are also based in the labour suite, as is the Sanctuary birth centre which is a four bedded midwife led unit.

Data from the trust reported that for the 12 months prior to the inspection, 3559 babies had been delivered at the QMC. Of these 1837 were unassisted deliveries, 511 were assisted deliveries, 535 were elective caesarean deliveries and 676 were emergency caesarean deliveries.

Community maternity services are provided by teams of midwives predominantly commissioned by NHS Nottingham and Nottinghamshire CCG. 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 3 and 4 March 2022. The inspection team comprised two inspectors, one midwife specialist advisor and one consultant specialist advisor. An inspection manager oversaw the inspection.

Our rating of maternity services stayed the same. We rated them as inadequate and have taken enforcement action as a result of this inspection to promote patient safety. We served a warning notice to the trust requiring them to make improvements to their triage services, at both the Nottingham City Hospital and Queens Medical Centre, to address safety concerns in respect of staff deployment and the oversight of risk and performance. The warning notice also requires the trust to make improvements in respect of their processes for observing women across all maternity services.

During our inspection we visited ward C29 (postnatal ward), B26 (antenatal ward) and the labour suite. We spoke with 28 staff including midwives, midwifery support workers, obstetricians, anaesthetists, managers and reception staff. We reviewed 11 patient records and nine patient prescription charts. We spoke with eight women and two fathers about their experience of the trust.

After the inspection we also held focus groups where we spoke with more midwives; some staff also contacted us separately to discuss their experience of working at the hospital.

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.

Nottingham University Hospitals NHS Trust provides a range of elective and emergency surgery at Queen’s Medical Centre. The surgical core service spans across five divisions at the trust including surgery, medicine, clinical support, ambulatory care and cancer and associated specialities. Surgical specialities at this location include neurology and neurosurgery, spinal surgery, ophthalmic surgery, orthopaedic surgery, colorectal surgery, general surgery, hepato-pancreatico-biliary surgery, vascular surgery and ear nose and throat surgery. There are 337 beds for surgical patients including both inpatient and day case surgery. There are 36 operating theatres at this location.

During our inspection we visited eight wards (C31, C32, D10, E14, E15, E16, F18 and F19), pre-operative assessment, theatres, recovery and the post anaesthesia care unit (PACU). We spoke with 12 patients and one relative and 44 members of staff. These included service leads, matrons, nurses, consultant surgeons and anaesthetists, junior doctors, therapists and healthcare assistants. We observed care and treatment and looked at 24 complete patient records.

We carried out an unannounced focused inspection of the emergency department at Queens Medical Centre on 14 July 2021 as part of our on-going regulatory oversight of the trust. We used our focused pressure resilience inspection methodology and did not explore all key lines of enquiry.

The emergency department (ED) at the Queens Medical Centre (QMC) is open 24 hours a day seven days a week and is a designated major trauma centre. It sees approximately 650 patients per day and includes a paediatric emergency department dealing with all emergency attendances under the age of 18 years.

Patients present to the department either by walking into the reception area or arrive by ambulance via a dedicated ambulance-only entrance. The department has different areas where patients are treated depending on their needs, including a resuscitation area; a 30 bed majors area with an additional six cubicles used during periods of escalation; 20 bed clinical decision unit; urgent treatment centre which was operated by a third party but was co-located at the main reception area of the ED; a Covid-19 isolation area; and a separate paediatric ED with its own waiting area and treatment cubicles within the department.

We looked at all areas of the department and we observed care and treatment. We looked at 15 sets of patient records. We spoke with 19 members of staff, including nurses, doctors, allied health professionals, managers, support staff and ambulance crews. We also spoke with six patients who were using the service at the time of our inspection. We reviewed and used information provided by the organisation in making our decisions about the service.

Summary findings

We carried out a focused desk based review of East Midlands Children and Young People's Sexual Assault Service (EMPCYPSAS) in October 2020.

The purpose of this review was to determine if the healthcare services provided by Nottingham University Hospital Trust (NUHT) were now meeting the legal requirements and regulations under Section 60 of the Health and Social Care Act 2008. We found that improvements had been made and the provider was no longer in breach of the regulations.

We do not currently rate the services provided in sexual assault referral centres.

During this desk based review we looked at the following questions:

Are services well-led?

Background:

The East Midlands Children’s and Young People’s Sexual Assault Service (EMCYPSAS) was provided from two regional hubs. The Serenity Suite in Northampton (inspected in 2018) and The Children and Young People’s Suite at the Queen's Medical Centre, Nottingham. This inspection looked at the well led aspects of paediatric sexual assault referral centre (SARC) services provided from The Children and Young People’s Suite at Queen's Medical Centre (QMC), Nottingham University Hospitals NHS Trust (NUHT).

The children and young people’s suite at the Queen's Medical Centre accepted referrals from children and young people who had been a victim of rape or serious sexual assault and reside in Derbyshire (including Derby City), Lincolnshire and Nottinghamshire (including Nottingham City) or if the assault had been committed in that area.

The SARC saw children and young people up to 18years and 18-24year olds with additional needs. There was an on-call out of hours rota for telephone advice and strategy discussions.

The suite was designed and refurbished to deliver paediatric SARC services with a dedicated forensic waiting and examination room. There was also a non-forensic waiting room. The areas had been made as child and young person friendly as possible. They were bright and secure. There had been refurbishment work to add an additional non recent clinical examination space however we have not seen this as we have not been onsite to complete this review. Nottinghamshire Sexual Violence Support Services (NSVSS) delivered a single point of access (SPA) for the regional service and provided crisis workers 24 hours a day to the Nottingham Hub. Self referrals were not accepted for children and young people aged 13yrs and under. With appropriate assessment young people over the age of 16yrs could self refer. All forensic examinations were completed by doctors. The suite was staffed by doctors, specialist nurses and crisis support workers.

We last inspected the service in November 2019 when we judged that NUHT was in breach of CQC regulations. We issued a requirement notice on 5 February 2020 in relation to Regulation 17, Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The report on the November 2019 inspection can be found on our website:

https://www.cqc.org.uk/location/RX1RA/reports

This desk based review was completed by a CQC children's services inspector. We reviewed evidence and had a telephone conversation with SARC staff including the clinical and governance leads for the service.

Prior to this review, we reviewed the action plan submitted by NUHT. This demonstrated how they would achieve compliance.

Documents we reviewed included:

EMCYPSAS risk matrix
Revised Quality, Risk and Safety (QRS) terms of reference
Completed Quality, Risk and Safety template
EMCYPSAS staff structure
SARC report for Quality Assurance Committee July 2020
Leaflets for patients pre and post examination
SARC reporting structure
Staff job descriptions and person specifications
EMPCYPSAS nursing metrics

We did not visit EMCYPSAS at Queens Medical Centre to carry out the desk based focused review. This was due to the Covid-19 pandemic and because we were able to gain sufficient assurance through documentary evidence provided and a telephone discussion.

At this inspection we found:

Local leadership capacity for the SARC service had been increased to support development of governance and management systems.
Analysis of risk was up to date and there was an oversight mechanism for risk through the Quality, Risk and Safety (QRS) group.
Lines of accountability were defined through the divisional reporting structure. We saw an example of a comprehensive report that identified strengths and areas that the SARC was still working on.
There was an agreed template for speciality services to report risk.
There was a clearly defined team structure with appropriate job descriptions. Staff had appraisals, opportunities to access training and had identified workplans to support their development.
The SARC had identified that there were ongoing issues regarding training for crisis support workers. They were working together with the subcontracted agency to ensure that all crisis support workers had accessed appropriate training.
The SARC continued to receive overwhelmingly positive feedback from patients.

In rating this location, we took into account the current ratings of services not inspected at this time.

Our rating of Maternity services went down. We rated them as inadequate because:

Queen’s Medical Centre is operated by Nottingham University Hospitals NHS Trust. The trust’s maternity service sits within the division of family health and provides a range of services from pregnancy, birth and post-natal care and is based across two campuses and Nottinghamshire community. The trust provides inpatient antenatal, intrapartum and postnatal beds on Nottingham University Hospital (NUH) City campus and Queen’s Medical Centre (QMC) campus for both high and low risk women. Both labour suites have alongside them midwifery led units and the trust provides a homebirth service. There are inpatient antenatal, intrapartum and postnatal beds available for women.

From January 2019 to December 2019 there were 8,265 deliveries at the trust.

Antenatal clinics are held across the whole of the service including community and the trust has day assessment units on both sites and ABC (triage service).

There is a fetal medicine service based on both sites, but this service is primarily delivered at the QMC campus.

Community services are provided by teams of midwives commissioned by Nottinghamshire CCG. They offer women a homebirth service and postnatal care.

The maternity unit at QMC is located over two floors in East block and includes:

Ward B26 - an18 bedded antenatal ward (includes triage and induction of labour as additional beds in a separate area of the ward)
Ward C29 – a 26 bedded postnatal ward which includes transitional care cots
Labour suite – 10 beds plus two obstetric theatres with 24-hour anaesthetic cover, a bereavement suite and direct access to the neonatal unit.
Sanctuary birth centre – 4 beds. A midwife led unit sometimes referred to as an Alongside Midwifery Unit (AMU)

We carried out a short notice, announced focused inspection at Queens Medical Centre on 15 October 2020. During this inspection we inspected maternity services which was in response to concerns raised from serious incidents, external investigations performed by Healthcare Safety Investigation Branch (HSIB) and coronial inquests.

We visited ward B26, ward C29, Labour suite and ABC triage assessment unit. We spoke with 22 staff, including service leads, matrons, midwives, medical staff, maternity care support workers and student midwives. We reviewed 18 sets of patient records (eight belonging to women and ten belonging to babies) and observed staff providing care and treatment to women.

Focused inspections can result in an updated rating for any key questions that are inspected if we have inspected the key question in full across the service and/or we have identified a breach of a regulation and issued a requirement notice or taken action under our enforcement powers. In these cases, the ratings will be limited to requires improvement or inadequate.

Following this inspection, under Section 31 of the Health and Social Care Act 2008, we imposed conditions on the registration of the provider in respect to the regulated activity; Maternity and midwifery services. We took this urgent action as we believed a person would or may be exposed to the risk of harm if we had not done so. Imposing conditions means the provider must manage regulated activity in a way which complies with the conditions we set. The conditions related to the maternity units at the Queens Medical Centre and Nottingham City Hospital. We also issued a section 29a warning notice to the trust as we found significant improvement was required to the documentation for risk assessments and information technology systems. The section 29a notice has given the trust three months to rectify the significant improvements we identified.

We carried out this announced inspection of East Midlands Children and Young People’s Sexual Assault Service (EMCYPSAS) over two days on 26 and 27 November 2019. We conducted this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements of the Health and Social Care Act 2008 and associated regulations. Two CQC inspectors, supported by a specialist professional adviser, carried out this inspection.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions about a service:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

Background

The East Midlands Children’s and Young People’s Sexual Assault Service (EMCYPSAS) was provided from two regional hubs. The Serenity Suite in Northampton (inspected in 2018) and The Children and Young People’s Suite at the Queen's Medical Centre, Nottingham. This inspection looked at the paediatric sexual assault referral centre (SARC) services provided from The Children and Young People’s Suite at Queen's Medical Centre (QMC), Nottingham University Hospitals NHS Trust (NUHT).

The service had been delivered by NUHT since April 2018 when there was a change in provision of paediatric and adult SARC services in the East Midlands. The regional model allowed better support for staff and sharing of knowledge and skills to benefit the patient experience. The children and young people’s suite at the Queen's Medical Centre accepted referrals from children and young people who had been a victim of rape or serious sexual assault and reside in Derbyshire (including Derby City), Lincolnshire and Nottinghamshire (including Nottingham City) or if the assault had been committed in that area. In cases that were close to the regional border, care of the patient and patient preference is paramount. If a patient chose to access a different service, staff told us that they were happy to manage the onward referrals and ensure the patient could access local aftercare services if they want to.

The SARC saw children and young people up to 18years and 18-24year olds with additional needs. There was an on-call out of hours rota for telephone advice and strategy discussions.

The centre was within a wing of the Queen's Medical Centre. Families and the police had dedicated parking so that they could access the centre via the most direct route. Access to the SARC was via a video intercom. A staff member from the SARC had to attend the entry door to allow access.

The suite was designed and refurbished to deliver paediatric SARC services with a dedicated forensic waiting and examination room. There was also a non-forensic waiting room. The areas had been made as child and young person friendly as possible. They were bright and secure. There was ongoing work and refurbishment to add a police suite and non-recent clinical space.

Nottinghamshire Sexual Violence Support Services (NSVSS) delivered a single point of access (SPA) for the regional service and provided crisis workers 24 hours a day to the Nottingham Hub.

Self referrals were not accepted for children and young people aged 13yrs and under. With appropriate assessment young people aged 14-17yrs could self refer. All forensic examinations were completed by doctors. The suite was staffed by doctors, specialist nurses and crisis support workers.

The hub had a rota of medical staff who completed the forensic examinations. This included Forensic Physicians and Paediatric Consultants. There was a Clinical Lead who was a member of The Royal College of Paediatrics and Child Health (RCPCH) who represents The RCPCH on the academic committee of The Faculty of Forensic and Legal Medicine (FFLM). In addition to being on the rota, the clinical lead provided staff support and had been instrumental in the setting up of the SARC. There were three specialist nurses who supported in examinations, referrals and day to day running of the SARC Monday to Friday. One nurse has a dual role providing clinical support and managing the SARC processes. In total the nursing establishment was 1.2 whole time equivalents. There were seven crisis support workers, a lead crisis support worker and a crisis support worker service manager.

On the day of inspection we spoke with 10 members of staff. We reviewed eight patients' records and seven safeguarding referrals. We left comment cards at the SARC in the two weeks prior to our visit and received 3 responses from patients who had used the service.

Throughout this report we have used the term ‘patients’ to describe people who use the service to reflect our inspection of the clinical aspects of the SARC’.

We looked at policies and procedures and other records about how the service was managed.

Our key findings were:

The service used systems to help them report risk.
The service had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
The service had thorough staff recruitment procedures.
Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
The clinical staff provided patients’ care and treatment in line with current guidelines.
Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
The appointment/referral system met clients’ needs.
The service had effective clinical leadership and a culture of continuous improvement.
Staff felt involved and supported and worked well as a team.
The service asked staff and clients for feedback about the services they provided. The feedback was overwhelmingly positive.
The staff had suitable information governance arrangements.
The service appeared clean and well maintained.
The staff had infection control procedures which reflected published guidance.

We identified regulations the provider was not meeting. They must:

Ensure that local leadership capacity means that all risks are identified.
Ensure that governance and management systems support local leaders to identify, address and manage risks.
Ensure a clear line of accountability through NUHT governance structures from the local SARC leaders to the trust board. This includes the use of locally agreed performance measures.
Ensure there is a clear system in place so that the service is continually improving in relation to staff learning plans and job role priorities.

Full details of the regulation/s the provider was/is not meeting are at the end of this report.

There were areas where the provider could make improvements. They should:

Identify competency frameworks for all staff groups.
Ensure ligature assessments are updated when there are changes to the physical environment.
Offer examination information for patients, families and carers to take away with them or have prior to the examination.

Our rating of services went down. We rated it them as requires improvement because:

Not all services had enough medical and nursing to keep people protected from avoidable harm and to provide the right care and treatment.
Not all services controlled infection risk well. Staff did not always keep equipment and the premises clean.
We were not assured of appropriate safety processes at service level for laser equipment in eye casualty. There were discrepancies between the services the trust believed were offered in the laser service and the services offered in practice. The most recent annual laser protection audit identified areas in need of significant improvement
Arrangements to admit, treat and discharge patients were not in line with national standards.
The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department. From October 2017 to September 2018 the trust failed to meet the standard and performed worse than the England average.
The Royal College of Emergency Medicine (RCEM) recommends that the time patients should wait from time of arrival to receiving treatment should be no more than one hour. From September 2017 to August 2018, the trust did not meet the standard for 11 months over the 12-month period.
In children’s services, outpatient appointments did not always run on time. Children and their families were not informed about delays in outpatients and the service did not monitor or analyse delays to outpatients. The outpatient environment could become very crowded for certain clinics
Lack of out of hours access to paediatric interventional radiology meant that some babies needed to be transferred to other hospitals.
In maternity, although the trust had made improvements to the leadership and governance structures, the changes had not yet been fully embedded and there was still a lack of oversight and assurance in some areas.
In maternity there was not a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

However:

Staff understood how to protect patients from abuse and the services 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 provided care and treatment based on national guidance and monitored patient outcome to monitor for the effectiveness.
Staff worked together as a team to benefit patients.
Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
Staff involved patients and those close to them in decisions about their care and treatment.
The trust planned and provided services in a way that met the needs of local people.
The services took account of patients’ individual needs.
Most of the services had a 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.
The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

This inspection was a focussed, responsive, unannounced inspection looking only at the adult emergency department and the short stay observational ward (Lyn Jarrett Unit). We did not inspect the children’s emergency department, the major trauma centre or the eye casualty. We inspected this service because of concerns about the trust’s performance against the four hour waiting time standard for emergency departments.

This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we found when we inspected and information given to us from patients, the public and other organisations.

Our key findings were as follows:

Patients did not have timely access to initial assessment and diagnosis.
There was a risk that high demand, unrelenting pressure and staff perception that they were providing a poor service would lead to a demoralised culture and a lack of service sustainability.
Call bells were not available in the majors cubicles and there was insufficient seating for patients waiting in reception and for relatives in the majors and resuscitation areas.
Staff did not always assess and respond to patient risks appropriately whilst they were waiting to be seen in the department but leaders responded swiftly to address and mitigate these risks when we brought them to their attention.
Ongoing issues with the implementation of a new computer system meant staff did not always have the information they needed to deliver effective care.
The overcrowding in the department made it difficult for staff to protect the privacy and dignity of patients.

However:

People were protected from avoidable harm and abuse. There was a good track record on safety. Standards of cleanliness and hygiene were generally well maintained, staff received effective mandatory training and there were appropriate nursing and medical staffing arrangements.
People’s care and treatment achieved good outcomes and was based on the best available evidence with staff, teams and services working together effectively. Patients’ pain was assessed and managed appropriately and they were given drinks and where appropriate food. Staff were given the skills and knowledge to deliver effective care and treatment and there was an ethos of continual learning in the department.
Despite the overcrowding in the department staff cared for patients with compassion, patience and kindness.
Services were planned and delivered to meet the needs of local people and individuals. People’s concerns and complaints were responded to and used to improve the quality of care.
Leadership, governance and culture were used to drive and improve the delivery of sustainable, high quality person-centred care. There was a supportive culture focussed on continuous learning with strong collaboration and support across all functions and a common focus on improving quality of care and people’s experiences.

We saw some outstanding practice including:

Nursing handovers, called ‘roll call’ took place in the emergency department at 7am and 7pm. All qualified and unqualified nursing staff attended. They were shown an electronic presentation of information including themes of complaints and any changes to practice. The outgoing nurse in charge gave information about the previous shift, patients in the department, cleaning and stock levels. A member of the department for research and education in emergency medicine, acute medicine and major trauma (DREEAM) team also attended to deliver short teaching sessions as appropriate. This staff member would also ensure agency staff had received an induction to the department which was recorded.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Nottingham University Hospitals NHS Trust is the fourth largest acute trust in England and provides services to more than 2.5 million residents of Nottingham and its surrounding communities. It also provides specialist services to between three and four million people from neighbouring counties. The trust is based in the heart of Nottingham on three separate sites around the city: Queen’s Medical Centre, Nottingham City Hospital and Ropewalk House. Queen’s Medical Centre is the emergency care site, where the emergency department, major trauma centre and the Nottingham Children’s Hospital are located.

Nottingham University Hospital NHS Trust were inspected as one of 18 CQC new wave pilot inspections in November 2013 but the trust was not rated at this inspection. The purpose of this comprehensive inspection was to award a rating to the trust for the services it provided. We carried out an announced inspection to the three hospital locations between 15 and 18 September 2015. Unannounced visits were carried out on 28 September to medical wards, children’s wards and the maternity department.

Overall, Queens Medical Centre was rated as good with some elements of outstanding. End of Life services however, required improvement.

Our key findings were as follows:

There was good incident reporting culture in the trust and staff, systems were in place to report incidents and largely there was effective learning from incidents. The exception to this was a backlog of radiology and maternity incidents where a lack of timely review may affect the ability to quickly implement any learning.

Staff mostly followed infection prevention and control policies and cleaned their hands between patients. There was mostly suitable hand cleansing facilities in place apart from one area where staff had to leave the toilet to wash their hands. Equipment was cleaned following use and was labelled appropriately.
Cleaning services were contracted out to a private provider. There had been problems with cleanliness prior to and following our inspection which were identified through the trusts own audits and those carried out by the Trust Development Authority. These were been monitored and action was being taken to improve. Progress was been closely monitored by the executive team. During our inspection, we generally found the hospitals to appear visibly clean.

Actual and planned staffing levels were clearly displayed across the trust and generally we found then actual levels were in accordance with the planned.

Although agency staff were used, overall the trust used slightly less bank and agency staff than the national average. There was an induction process for agency staff to make sure they were familiar with their working environment.
For end of life services we found that there was strong leadership for specialist palliative care services but this was not extended to end of life care provided on other wards.

We saw several areas of outstanding practice including:

Urgent and emergency care services

In January 2015 the NHS invited individual organisations and partnerships to apply to become ‘vanguard’ sites for the new care models programme. Vanguards are where groups of providers come together to change the way they work together to provide more joined up care for patients. Nottingham University Hospitals along with partners in the South Nottinghamshire health community were awarded vanguard status for urgent and emergency care. This has allowed the trust to trial new approaches to improve the coordination of services, and reduce the pressure on A&E departments.
Working with four local clinical commissioning groups, GPs, and out of hours GP services, the trust reduced unnecessary hospital admissions from 28% to 5% following the launch of the Nottingham Care Navigator programme. This programme offered an alternative to urgent hospital admission, where possible, providing direct access to advice and support from the right clinical service first time via an online health navigation tool.
During 2014 the trust piloted having GPs at the front door of A&E on two separate peak activity weekends. As a result, patients seen by a GP spent 50 minutes less in the department. There was also a reduction in patients needing to be seen by the minor illness and injury teams. The findings showed 54% of patients were redirected away from A&E to more appropriate services, with the majority being directly discharged home.
The trust was delivering an Injury Minimisation Programme for Schools (IMPS) in partnership with schools and a public health organisation. The programme was designed with the aim of educating children aged 10 and 11 to recognise potentially dangerous situations and prevent injuries. Small groups of children from Nottingham city schools attended the children’s emergency department each morning to learn first aid and resuscitation skills, helping them to respond effectively to accidents and take safe risks. More than 2,300 children received health education through this programme each year

Medical care (including older people’s care)

An occupational therapist on ward F20 had undertaken a six month pilot project called ‘Playlist for life’. The project involved asking patients about songs that were personal to them that they would like to listen to. Where patients were unable to list songs that were personal to them, their family or carers were encouraged to create a playlist on the patients behalf. The playlists were then created using hand held devices and provided to patients free of charge. Evaluation of the project was underway.
With the support of nursing staff, a consultant on ward F20 had started an ice cream project in order to support patients who were nutritionally at risk. Patients who were nutritionally at risk had an ice cream sign placed on the board above their bed, this prompted staff to ensure these patients were supported to eat ice cream. The project had come to an end and the consultant was working on applying for more funding to continue the ice cream project.
Patients wore a coloured wrist band to highlight the oxygen rate they were prescribed. This ensured staff could easily identify the patient’s required rate to ensure they were receiving safe care.

Surgical services

Theatre staff had successfully standardised practices and processes at QMC and Nottingham City Hospital to ensure safe ways of working and reduce cultural differences. The theatres safety improvement programme implemented a variety of safety projects. It ensured that all theatre staff were trained on team etiquette. This emphasised safety, mutual respect, effective communication, accountability and situational awareness. As a result, theatres ran more safely and efficiently.
There was a ‘Dragons Den’ project where staff could present their ideas for service improvements. Theatre staff had been successful in presenting their ideas for improvements in equipment used in vascular surgery at QMC.
The theatre PPI group had been shortlisted for a Nursing Times Award for Enhancing Patient Dignity and were due to present their work in September 2015.
The theatre PPI group were working on a DVD to show to patients before their operation. The DVD will show patients what to expect when coming to theatres to help reduce fear and anxiety.

Critical care services

Innovative approaches were used to gather feedback from people who used the service through inviting patients and carers to opening of a new bed area and getting their views regarding patient privacy.
The ‘just do it’ project to avoid cancelled elective surgery due to lack of critical care beds has been successful. This is also an example of several departments working together to solve a problem.

Maternity and gynaecology services

A member of staff designed a maternity app specifically for the women at NUH called the ’Pocket Midwife’. The free ‘app’ had information about each stage of pregnancy, including leaflets and information. The service could add news flash information to the app for women to see, for example flu vaccinations alerts. Maternity leaflets and trust guidelines were easily accessed via a guideline app.
Maternity services identified successful processes within the hospital and engaged with the staff who were involved. For example the ‘breaking the cycle team’ had been successful in reducing emergency waiting times. This team were invited to work with maternity services to improve the efficiency of the discharge process.

Outpatients and diagnostic imaging

In recognition of the challenge to outpatient services, in July2014 the trust came together with five other NHS trusts from across the country to share good practice and highlight themes for development. This was reported in the Health Services Journal.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

The trust must take action to ensure that nursing staff working in the eye casualty receive training in the recognition and treatment of sick children.
In surgical services the trust should take action to ensure that the principles of the Mental Capacity Act 2005 are correctly and consistently applied in assessing the capacity of patients to make specific decisions
The trust must ensure 50% of nursing staff within critical care have completed the post registration critical care module. This is a minimum requirement as stated within the Core Standards for Intensive Care Units.
The trust must ensure midwives have appropriate training to provide safe care for high dependency women in an appropriate environment.
The trust must ensure midwives have the appropriate competence and skills to provide the required care and treatment to women who are recovering from a general or local anaesthetic.
The trust must be consistent in the documentation of checking of emergency equipment and ensure that the resuscitation trolleys, neonatal transport systems and resuscitation equipment are checked, properly maintained and fit for purpose in all clinical areas.
The trust must take action to ensure Do Not Attempt Cardio-Respiratory Resuscitation decisions are documented legibly and fully in accordance with the trust’s policy and the legal framework of the Mental Capacity Act 2005.

In addition the trust should:

The trust should consider holding major incident exercises in the emergency department and ensure that staff in all specialities are familiar with emergency planning and major incident procedures
The trust should consider improving the availability of patient information leaflets, including those in other languages and accessible formats.
The trust should consider the appropriateness of the environment and facilities in the eye casualty waiting area for children and young people.
The trust should consider nurse staffing levels and skill mix in the eye casualty department.
The trust should consider availability of consultants to ensure direct admission and transferred major trauma patients are seen by a consultant within five minutes of arrival at the major trauma centre.
Providers should ensure staff follow policies and procedures to ensure medicines are administered appropriately to make sure people are safe.

The trust should consider measures to increase the number of nurses receiving appraisals in the emergency departments.
The trust should consider the availability of hospital play specialists in the children’s emergency department.
The trust should ensure oxygen is prescribed in line with the trust’s policy for patients who require it.
The trust should ensure consistency in the completion of patient’s nutritional screening and the completion of nutrition and fluid charts on ward B49.
The trust should ensure all staff are aware of their responsibilities in relation to infection, prevention and control.
The trust should consider placing hand washing facilities inside staff toilets to reduce the risk of the spread of infection.
The trust should ensure patients on all of the health care of older people (HCOP) wards have equal access to meaningful activities.
The trust should ensure pre-printed care plans are consistently personalised to each individual’s needs.
The trust should ensure care plans reflect how staff should support patients who present with complex and challenging behaviour.
Ensure that ward temperatures are regulated and that a system is in place to date check equipment in a timely manner
Put patients at their ease before they go into theatre by providing a suitable waiting area with privacy
Continue to make efforts to help patients sleep by mitigating noise levels on wards at night.
The trust should consider using the emergency planning boards on all wards to ensure important information is easily available for staff.
The trust should consider improving the experience of patients at mealtimes by serving each course separately.
The trust should consider extending the availability of the Learning Disability Liaison team to include weekends.
The trust should work towards there being at least one nurse per shift in each clinical area (ward / department) within the children’s and young people’s service is trained in advanced paediatric life support or European paediatric life support.
A lack of specialist radiology cover out of hours meant that babies had to be transferred to another hospital to receive this service. The trust should consider how the service can be improved to ensure radiology care could be delivered on site.
The trust should ensure that staff in the maternity service have received up to date training for the safe operation of equipment.

The trust should ensure that staffing within the neonatal unit follows the British Association of Perinatal Medicine standards
The trust should ensure that an accurate record is kept for each baby, child and young person which includes appropriate information and documents the care and treatment provided.
The trust should ensure that they have written formal arrangements in place with the children and adolescent mental health team so that the needs of children and young people with mental health problems are met.
The trust should ensure all midwifery guidelines are available for staff to use when providing care.
The trust should work towards capturing the users’ comments on the partners in maternity committee.
The trust should review the home from home values of the midwife led unit.
The trust should ensure medical staffing ratios in midwifery meet national recommendations.
The trust should review the elective caesarean section pathway to improve the experience for women and families.
The trust should consider formulating an overall strategy for end of life care across the trust which is disseminated to all staff across all divisions.
The trust should consider increasing the number of consultants providing end of life care to reflect the recommendations of the National Council of Palliative Care.
The trust should consider increasing the hours of the specialist palliative nursing team to ensure patients who require it can receive a face-to-face consultation seven days a week as per NICE (National Institute for Health and Care Excellence) Quality Standard number 10 published in 2011 for end of life care for adults.
The trust should consider ensuring end of life ‘champions’ are allocated protected time to disseminate matters relating to good practice end-of life care to other staff in their team.
The trust should consider updating the end of life care bundle to ensure a patient’s preference for involvement of the pastoral care team is recorded.
The trust should provide a structured programme of end of life care training for all staff to ensure patients receive appropriate care at the end of their life.
The trust should ensure effective monitoring of ‘fast-track’ discharges and compliance with patients’ wishes regarding preferred place of care and preferred place of death. Good practice in these areas should be shared across the trust and appropriate action taken to address any issues.
The trust should consider ensuring up to date information reflecting good practice at end of life is readily available in each area and staff are aware of its location.
The trust should ensure all staff have access to on-going training for end of life care to ensure staff understand their roles in delivering quality care.
The trust should ensure regular auditing of ‘fast-track’ discharging and patients preferred place of death is undertaken to identify any concerns and put actions in place to address the issues
Ensure that all reports of radiation incidents are investigated in a timely manner, and ensure recommendations are put in place in a reasonable timescale.
Ensure all staff are able to attend annual fire safety training.
Ensure that small portable sanitising hand gel dispensers are safe to use in outpatient departments.
Ensure that the risks of lone working are reviewed and managed in all relevant outpatient and diagnostic departments.
The trust should ensure the system for maintaining and testing clinical equipment is timely, effective and consistent to ensure it is safe to use.
Extend outpatient and diagnostic imaging services beyond working hours, Monday to Friday.
Improve the outpatient appointment booking procedures to reduce the rate of cancelled appointments.
Improve the visual environment in the eye centre.
Provide varied seating in outpatient waiting areas to meet different people’s requirements.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Queen’s Medical Centre is an acute hospital managed by Nottingham University Hospitals NHS Trust. The trust is the fourth largest acute trust in England, and provides services to more than 2.5 million residents of Nottingham and its surrounding communities. It also provides specialist services to between three and four million people from neighbouring counties. There are 1,690 beds across the trust, and it has a budget of £824 million. Queen’s Medical Centre is the emergency care site, where the emergency department, major trauma centre and the Nottingham Children’s Hospital are located. There are 975 beds on this site.

The trust employs more than 14,000 people. Of the population of Nottingham, 34.6% belong to non-white minority groups.

We chose to inspect the acute services at Queen’s Medical Centre as one of the Chief Inspector of Hospital’s first new inspections because we were keen to visit a range of different types of hospital, from those considered to be high risk to those where the risk of poor care is likely to be lower. When we announced our inspection, we described the trust as a high risk provider. By the time we carried out the inspection, our risk methodology had revised that assessment to a medium risk provider. Queen’s Medical Centre has been inspected six times since it was registered in October 2010.

The trust scored better than the national average in the CQC 2012 Inpatient Survey and the NHS Friends and Family Test, which asks patients if they would recommend services to people they know. We found some good examples of caring and compassionate care.

In general, we found that Queen’s Medical Centre provided safe care. Most areas had good processes in place to recognise, investigate and learn from patient safety incidents. The hospital also responded well to the needs of its patients. Patients reported that there were good interpreting services. Written information was available in other languages on request.

The accident and emergency (A&E) department was seeing increasing numbers of patients, and it could not always maintain the privacy and dignity of all of its patients.

The trust calculated nurse staffing levels for services (with the exception of children’s care services) using a recognised dependency tool. It was currently developing a staffing dependency tool for children’s services.

We found some examples of good leadership in the hospital, and most staff felt very well supported by their managers. Many said that they had excellent training and development opportunities. Doctors who were in training also felt well supported and said that the consultants provided effective supervision.

The vast majority of people we spoke to said that their care had been positive, and we saw some good examples of staff delivering compassionate care to patients. Nevertheless, some people highlighted areas where they thought the hospital needed to improve.

We found that there was a back log of maintenance of clinical equipment. The trust was already aware of this and it was on their risk register. We found they had taken steps to manage this risk by making sure the more high risk equipment, such as ventilators which are used to breathe for patients were serviced according to manufacturer’s instructions. We also found that about 40% of staff were not up to date with their mandatory training. Again, the trust were already aware of this issue and had a plan in place to address the shortfall. We found they were making good progress against their plan and we did not find any impact on patient care.

We carried out this inspection in response to information received raising concerns about staffing levels on ward D57, an emergency assessment ward at the Queen's Medical Centre.

We had previously inspected ward D57 on 19 July 2013 and found that there were not always enough qualified, skilled and experienced staff to meet people's needs. We set a compliance action and the trust provided us with an action plan setting out the actions they would take in response to our report. Most actions had been timetabled to have been completed at the time of our most recent inspection but not all.

We spoke with four patients who were on the ward during our inspection and asked about staffing levels on the ward. We were told by one patient, 'It's been fine, I think there are plenty of staff.' Another patient said, 'The staff have been very caring and come to help when I've needed it.' A further patient said, 'They've been good on this ward, kept my water topped up and kept checking I am alright.'

We spoke with four relatives of patients who were present during our inspection. One person said, 'We have been seen to pretty quickly on this ward, I am quite happy with the staffing levels.' Another person said, 'There seem to be plenty of staff around, they've been to talk with my relative and let us know what's happening.'

We spoke with eight members of staff who gave us mixed information about the staffing levels on the ward.

We found there were enough qualified, skilled and experienced staff to meet people's needs on ward D57. We also found that the trust was taking action to address the concerns being raised by staff on this ward.

We visited two wards during the inspection. We looked at staffing levels on ward D57 and consent processes on ward F22. We spoke with 14 patients, one relative and nine staff. We looked at five patient records.

Patients told us that they were asked for their consent before they received any care or treatment. All patients told us they signed a consent form. Three of the four patients told us they had not received a copy of the consent form. A patient said, 'Yes, they sit and talk to me, they make sure I understand what is happening. They tell you properly and ask me if I have any questions. Yes, I have had to sign a few consent forms. They go through it on this ward, tell me any complications and ask if I have any questions then I sign it. I don't get a copy.'

Nine of the ten patients we asked told us they felt there was enough staff to meet their needs. A patient said, 'They have time to care.' Another patient said, 'There are enough staff and they have been respectful and caring. The staff are spread evenly.' The patient who did not feel their needs were met said, 'I think there are enough staff but they need to be better organised.'

We found that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. However, we also found that there were not always enough qualified, skilled and experienced staff to meet people's needs on ward D57.

Patients told us their privacy and dignity were respected and they were asked for their consent before they received any care or treatment. Patients told us they were happy with the care and treatment they received and felt safe. They knew who to speak to if they had concerns. Patients told us they had no concerns about the environment or the confidentiality of their records.

We found that patients' privacy and dignity were respected and staff obtained consent before carrying our treatment. Patients received appropriate care and treatment and received appropriate nutrition and hydration. The provider worked effectively with other providers and there were arrangements in place to ensure the safety of patients. The premises were appropriate and records were kept securely. However, records were not always accurate and fit for purpose.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Most patients told us that they understood the care and treatment choices available to them. One patient said, "I've been given literature about my condition and treatment each step of the way to help me take it all in and help me reflect, I know I'm in the driving seat." However, one patient told us that they had not been given enough information to enable them to make an informed choice about treatment.

Patients told us that they could express their views and were involved in making decisions about their care and treatment. One patient said, "I'm in control, they give me the information I need and I make my own decisions." Patients told us their privacy and dignity was respected.

Patients told us that they were able to give consent to the care and treatment that they received. They also told us that they understood and knew how to change any decisions about care and treatment that had been previously agreed.

One patient told us they were very satisfied with the way their individual care needs had been assessed and managed. Another patient said, "I've had ultrasounds and x-rays, and other procedures in other departments and they've all been brilliant." Some patients had experienced delay in the implementation of their assessment and treatment plans. Two patients expressed their frustration that they had not been told about delays to their planned procedures. Neither patient had been told to anticipate delays nor were they given an explanation of the reason for the delay and what was being done to address the problems.

One patient told us that the food was fine but said, "Then again, I'd eat anything, it's not always that hot but I don't mind that." One patient said, "[The food was] absolutely diabolical, even the sandwiches are old, pre-packed, dry and awful." Another patient said, "The food is very poor, lukewarm at best."

One patient thought the liaison between services was, "excellent." Another patient told us that there had been very good communication between departments and that information had been shared with them so that they knew what was happening and planned for them. However, three patients we spoke with in the discharge lounge had experienced significant delays waiting for their prescriptions to be filled by the hospital pharmacy and for transport to take them home.

Patients told us that they felt safe and they knew who to speak to if they had any concerns. Patients told us that they were happy with the premises.

Patients told us that their needs were met by competent staff. They also told us that staff were well trained and worked hard. Most patients knew where their records were kept and were happy they were available for staff to use but kept secure enough so as to be safe and confidential.

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.

All Inspections

Summary findings

Background:

Professor Sir Mike Richards

Professor Sir Mike Richards