Source · CQC inspection

Queens Hospital

Provider University Hospitals of Derby and Burton NHS Foundation Trust Type NHS Healthcare Organisation Region West Midlands Last inspected 12 May 2026

Overall rating: Good View full CQC report

Domain ratings

Five CQC key questions

Safe

Good

Effective

Good

Caring

Good

Responsive

Good

Well-led

Good

Current CQC assessment

Single Assessment Framework

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

Good Assessed 12 May 2026

The service is performing well and meeting our expectations.

Date of inspection: 11 November 2025.Queens Hospital Burton is part of University Hospitals of Derby and Burton NHS Foundation Trust. The hospital is the principal provider of acute hospital services for the residents of Burton upon Trent and surrounding areas including South Staffordshire, South Derbyshire and North West Leicestershire. This was the first inspection of Outpatients and Diagnostic Imaging using the single assessment framework. The services were rated as good. Following this inspection the rating at Queens Hospital has improved from requires improvement to good

Ratings by service

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

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.