Source · CQC inspection

The Queen Elizabeth Hospital

Provider The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust Type NHS Healthcare Organisation Region East Last inspected 8 Jul 2026

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

Current CQC assessment

Single Assessment Framework

From 2024 CQC rates services through ongoing assessments rather than comprehensive inspections.

Requires Improvement Assessed 8 July 2026
The service is not performing as well as it should and we have told the service how it must improve.
The Queen Elizabeth Hospital Kings Lynn provides a range of NHS hospital services.Date of assessment: On the 17 and 18 March 2026 we carried out an assessment of surgery.The rating of surgery has been combined with the ratings of the other services from the last inspections. See our previous reports to get a full picture of all the other services at The Queen Elizabeth Hospital Kings Lynn.The rating of The Queen Elizabeth Hospital Kings Lynn remains requires improvement.

Ratings by service

Surgery
Requires Improvement
Jan 2026

Regulatory breaches & enforcement

Current-framework "must do" equivalent

Breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, stated verbatim in the CQC assessment.

Breaches identified (2)

Breach Safe
The service breached legal regulations relating to safe care and treatment, and to premises and equipment.
Regulation: Regulation 12 (Safe care and treatment) · 8 Jul 2026
Breach Overall
During our assessment, we found concerns which resulted in a breach of regulation.
· 8 Jul 2026

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