Source · CQC inspection

The Queen Elizabeth Hospital

Type NHS Healthcare Organisation Region East Last inspected 1 Mar 2024

Overall rating: Requires Improvement  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement

Earlier inspection findings

pre-2024 framework · 5 must-do 5 should-do

Must-do actions (5)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 5
Must do
Safe
The service must ensure staff complete and document fresh eyes observations in line with national and trust guidance.
Regulation: Regulation 12(1)(2)(a)(b)
⚠ WelookedattheCTGandfresheyesauditinformationforJanuarytoSeptember2023andfoundfresheyeswerenotcompletedoftenenough.Althoughthiswasimproving,inSeptember2023fresheyescheckswereonlyrecordedascompleted53%ofthetime.Againstatrusttargetof90%
Must-do action 2 of 5
Must do
Safe
The service must ensure staff escalate and document adverse baby observations.
Regulation: Regulation 12(1)(2)(a)(b)
⚠ JustoverhalfoftheNEWTTscoresthatrequiredescalation,hadbeenappropriatelyescalated.Ofthosethathadnotbeenescalated,halfhadno documentationtoshowwhetheranyactionhadbeentakenatall.
Must-do action 3 of 5
Must do
Safe
The service must ensure women and birthing people are seen within appropriate timelines by medical staff when presenting to maternity triage.
Regulation: Regulation 12(1)(2)[MA1](a)(b)
⚠ However,only60%ofwomenwhoneededtobereviewedbyadoctorsawonewithinthecorrecttimeframe.
Must-do action 4 of 5
Must do
Safe
The service should ensure staff are up to date with maternity mandatory training modules.
Regulation: Regulation 18(1)(2)(a)
⚠ Recordsshowed that66%ofmidwiferystaffhadcompletedtherequiredmaternityspecificmandatorytrainingcoursesagainstatrusttargetof80%.Complianceinthemidwife-ledbirthingunitscoredabove80%.However,theoverallmandatorytrainingcompliancerateformaternitysupportworkers(MSW)was70%andtheoverallmaternityspecificmandatorytrainingcompliancerateformedicalstaffwas68%.Thiswasbelowthetrustcompliancetargetof80%.
Must-do action 5 of 5
Must do
Well-led
The service should ensure all staff are supported through supervision and appraisals to carry out their duties.
Regulation: Regulation 18(1)(2)(a)
⚠ Datashowed76%ofmidwiferystaffhadreceivedanappraisalintheprevious12months,againstatrusttargetof90%.

Should-do actions (5)

Recommended improvements to enhance service quality.

Should-do action 1 of 5
Should do
Safe
The service should ensure staff whomay have to provide care for out-of-scope events are giving training to do so.
Should-do action 2 of 5
Should do
Well-led
The service should ensure all incidents are investigated in a timely way.
Should-do action 3 of 5
Should do
Well-led
The service should ensure maternity telephone triage monitoring allows for detailed data collection.
Should-do action 4 of 5
Should do
Safe
The service should ensure discarded controlled medicines are recorded in line with trust guidance.
Should-do action 5 of 5
Should do
Safe
The service should ensure emergency equipment is checked daily in line with their procedures.

Location details

CQC ID: RCX70
Local authority: Norfolk
Region: East

Inspection report

Type: Location
Date: 1 March 2024
Rating: Requires improvement
Actions: 5 must-do 5 should-do
AI-extracted 3 Jun 2026