Home / Sources / CQC / Queens Hospital
Source · CQC inspection

Queens Hospital

Provider University Hospitals of Derby and Burton NHS Foundation Trust Type NHS Healthcare Organisation Region West Midlands Last inspected 4 Sep 2026

Location rating: Requires Improvement  View location on CQC

Location ratings by domain

Five CQC key questions

Ratings held for this CQC location under the Single Assessment Framework, assessed 4 September 2026. Ratings extracted from individual reports are shown separately below.

Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Good
Well-led
Good

CQC assessments indexed

Single Assessment Framework

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

Requires Improvement
The service is not performing as well as it should and we have told the service how it must improve.
Queen's Hospital Burton is part of University Hospitals of Derby and Burton NHS Foundation Trust. Thehospital is the principal provider of acute hospital services for the residents of Burton upon Trent andsurrounding areas including South Staffordshire, South Derbyshire and North West Leicestershire.We inspected two assessment service groups from 9 to 10 February 2026; medical care (including olderpeople's services) and urgent and emergency care. As a result of this inspection our rating for thislocation went from good to requires improvement.We found breaches of the regulations in relation to safe care and …

Ratings by service

Medical care (Including older people's care)
Good
Nov 2025
Urgent and emergency services
Requires Improvement
Nov 2025
Diagnostic imaging
Good
Sep 2025
Outpatients
Good
Sep 2025
Diagnostic imaging
Good
Sep 2025
Outpatients
Good
Sep 2025
Maternity
Requires Improvement
Apr 2025
Critical care
Good
Feb 2025

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.

Urgent enforcement Overall
This was an unannounced assessment to review compliance against the urgent enforcement action we took in August 2023.
· 7 Nov 2025 · CQC source

Breaches identified (4)

Breach Well-led
We identified breaches of 3 regulations around the failure to provide timely treatment, management of substances hazardous to health, not always having safe staffing levels, and improvements needed in governance.
Regulation: Regulation 18 (Staffing) · 4 Sep 2026
Breach Well-led
We identified breaches of 3 regulations around the failure to provide timely treatment and suitable medicines storage; not always having safe staffing levels; and lack of privacy and dignity.
Regulation: Regulation 18 (Staffing) · 4 Sep 2026
Breach Safe
We found breaches of the regulations in relation to safe care and treatment, staffing, governance and privacy and dignity.
Regulation: Regulation 12 (Safe care and treatment) · 4 Sep 2026
Breach Overall
We have requested an action plan to show how the service will meet the breaches of regulation, this will be requested upon publication of the final report.
· 4 Sep 2026

Most recent report indexed for actions

The date and rating here are from an individual report, not necessarily the location's latest assessment. Report ratings are extracted with AI; verify the original PDF.

Type: Location
Date: 29 November 2023
Rating extracted from this report: Requires Improvement
Actions indexed: 10 must-do 1 should-do

Read this inspection PDF

AI-extracted 2 Jun 2026

Earlier inspection findings

pre-2024 framework · 10 must-do 1 should-do

Must-do actions (10)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 10
Must do
Safe
Ensure staff have access to an evidence-based standardised risk assessment and prioritisation tool for maternity triage.
Regulation: Regulation 12(2)(a)(b)
⚠ There was no formal risk assessment tool in place for maternity triage, which meant women and birthing people were at risk of harm and could not be seen and prioritised in a timely manner depending on their presenting condition.
Must-do action 2 of 10
Must do
Safe
Ensure actions to reduce the risk of and manage post-partum haemorrhage and major obstetric haemorrhage is embedded and routinely followed by staff.
Regulation: Regulation 12(2)(a)(b)
⚠ Post-partum haemorrhage (PPH) risk assessments were not being routinely completed by staff, and the rates of Major Obstetric Haemorrhage (MOH) had risen above the national average.
Must-do action 3 of 10
Must do
Safe
Ensure compliance with accurate interpretation and escalation of fetal monitoring traces is regularly audited.
Regulation: Regulation 12(2)(a)(b)
⚠ Staff compliance with yearly fetal monitoring training and competency assessments was low, meaning the service could not be assured staff had the appropriate skills to identify and appropriately escalate deterioration in fetal health.
Must-do action 4 of 10
Must do
Well-led
The trust must ensure there is enough CTG equipment, and that staff receive regular training and competency assessment and consistently follow trust policy.
Regulation: Regulation 17(1)(2)(a)
⚠ The service did not always have enough suitable equipment, with regular instances of CTG equipment not working, and staff had only 3 CTG machines to share between 9 service users. Staff compliance with yearly fetal monitoring training and competency assessments was low, and staff had not been given formal training …
Must-do action 5 of 10
Must do
Safe
Ensure staff complete yearly obstetric emergency skills and drills training, including pool evacuation training.
Regulation: Regulation 12(2)(c)
⚠ Staff did not always complete mandatory training, and compliance with Practical Obstetric Multidisciplinary Training (PrOMPT) was low. The service could not be assured staff had completed skills and drills for safe pool evacuation in an emergency.
Must-do action 6 of 10
Must do
Safe
Ensure staff are up to date with yearly appraisals and maternity mandatory training including, cardiotocograph interpretation, safeguarding adults’ level 3 and safeguarding children level 3.
Regulation: Regulation (12(2)(c)
⚠ Only 79% of staff had completed an appraisal, which is outside the trust's target of 95% compliance. Mandatory training compliance was low, with 55% of midwifery staff and 86% of medical staff completing required courses, and insufficient attention to Level 3 safeguarding adults and children training.
Must-do action 7 of 10
Must do
Safe
Ensure infection prevention control audits regularly are completed.
Regulation: Regulation 12(2)(h)
⚠ The service did not always control infection risk well, and managers did not regularly complete cleaning audits. Monthly hand hygiene audits on delivery suites were only completed in 4 out of 12 months.
Must-do action 8 of 10
Must do
Safe
Ensure staff follow handover processes and to ensure patients are seen within target timeframes.
Regulation: Regulation 12(2)(a)(b)
⚠ There was no standardised way to handover information, and leaders did not monitor waiting times to ensure women and birthing people could access emergency services when needed and received treatment within agreed timeframes and national targets.
Must-do action 9 of 10
Must do
Well-led
Ensure effective governance and oversight of audits and action plans developed to improve performance, including analysis of key performance indicators by ethnicity and deprivation.
Regulation: Regulation 17(1)(2)(a)(b)
⚠ Leaders did not operate effective governance processes, and there were significant failures in audit systems and processes. Key performance indicators were missing from the maternity dashboard, and there was a lack of attention to the analysis of KPIs by ethnicity and deprivation.
Must-do action 10 of 10
Must do
Caring
Assess and implement systems and processes to ensure service users are treated with dignity and respect as well as taking reasonable steps to ensure service users can shower or carry out tasks in a way that protects their privacy and dignity.
Regulation: Regulation 10(1)(2)(a)
⚠ Staff did not always feel respected, supported, and valued, with trends in feedback from women reporting they were not treated with kindness or respect. Women had limited access to showers (2 for 26 beds) and were encouraged to shower with doors ajar due to ventilation issues, with no privacy curtains.

Should-do actions (1)

Recommended improvements to enhance service quality.

Should-do action 1 of 1
Should do
Caring
Should make sure staff meets service users’ needs and reflect their preferences as well as ensuring full informed consent is obtained before providing appropriate care and treatment that meets service user’s needs.