Home / Sources / CQC / Queen Elizabeth The Queen Mother Hospital
Index live
Source · CQC inspection

Queen Elizabeth The Queen Mother Hospital

Provider East Kent Hospitals University NHS Foundation Trust Type NHS Healthcare Organisation Region South East

Overall rating: Requires Improvement  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Requires Improvement
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
The service is not performing as well as it should and we have told the service how it must improve.
The Queen Elizabeth Queen Mother Hospital is operated by East Kent Foundation NHS Trust. The maternity service sits within the maternity and women’s directorate and provides a range of services from pregnancy, birth and postnatal care. Out- patient services include an early pregnancy unit, antenatal clinics, and a fetal medicine unit. In-patient services include antenatal, intrapartum, postnatal beds and a bereavement suite. There is a mixed antenatal and postnatal ward and a triage service which is accessible 24 hours-a-day. The is a midwifery-led unit and the labour ward has 7 …

Ratings by service

Maternity
Good
Oct 2024

Earlier inspection findings

pre-2024 framework · 42 must-do 32 should-do

Must-do actions (42)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 42
Must do
Responsive
The trust must operate an effective complaints procedure which includes providing timely responses and updates to complainants.
Regulation: Regulation 16(2)
⚠ The trust did not always deal with complaints within expected timeframes.
Must-do action 2 of 42
Must do
Safe
The trust must ensure all staff report incidents via the trust reporting systems.
Regulation: Regulation 17
⚠ near misses, including those with potential for harm were not always reported.
Must-do action 3 of 42
Must do
Safe
The trust must ensure the risks associated with reported safety concerns are mitigated promptly.
Regulation: Regulation 17
⚠ there was variability and a lack of pace in the trust response to mitigate and manage these in some core services.
Must-do action 4 of 42
Must do
Well-led
The trust must ensure medical staff complete exception reports to identify trends and themes and use these to improve services for patients and staff.
Regulation: Regulation 17
⚠ Medical staff had fed back to the guardians of safe working hours that they did not know how to exception report and felt it was a ‘tedious system’, ‘didn’t always work’ and ‘took too long’ to complete.
Must-do action 5 of 42
Must do
Safe
The trust must ensure that all staff maintain effective oversight of patients for the duration of their care within the ED. For example, ensuring patients are regularly assessed and reassessed clinically.
Regulation: Regulation 12(1)(2)(a)(b): Safe care and treatment
⚠ Staff did not always identify and quickly acted upon patients at risk of deterioration.
Must-do action 6 of 42
Must do
Safe
The trust must ensure medical and nursing staff are up to date with mandatory training in key skills. This includes safeguarding adults and children training to the appropriate level.
Regulation: Regulation 18(1)(2)(c) Staffing
⚠ Safeguarding training was below trust targets for medical staff.
Must-do action 7 of 42
Must do
Caring
The trust must ensure that patients are treated with dignity and respect at all times, including during medical and clinical assessments when in overcrowded areas.
Regulation: Regulation 10(1): Dignity and respect
⚠ Overcrowded departments meant patients privacy and dignity could not always be respected.
Must-do action 8 of 42
Must do
Safe
The trust must ensure that the premises are appropriately maintained and fit for purpose. For example, ensuring reception and assessment areas are fit for purpose and risk assessed, escalation areas are appropriately risk assessed and completing required maintenance on the mental health assessment room doors.
Regulation: Regulation 15(1) Premises and equipment
⚠ The design, maintenance and use of facilities, premises and equipment did not always keep people safe.
Must-do action 9 of 42
Must do
Safe
The trust must ensure that fire safety risks associated with an overcrowded department are assessed and mitigated. For example, with regard to trolleys blocking corridors and fire exits.
Regulation: Regulation 12(1)(2)(d) Safe care and treatment
⚠ The design, maintenance and use of facilities, premises and equipment did not always keep people safe.
Must-do action 10 of 42
Must do
Safe
The trust must ensure all staff received mandatory training.
Regulation: Regulation 18(2)(a)
⚠ Staff across all roles did not always receive and keep up-to-date with their mandatory training.
Must-do action 11 of 42
Must do
Safe
The trust must ensure all staff receive training in safeguarding adults and children.
Regulation: Regulation 18(2)(a)
⚠ Medical staff were 100% compliant with safeguarding training level 1 but were below trust targets for level 2 and 3 safeguarding training, where only 76% had completed training.
Must-do action 12 of 42
Must do
Safe
The trust must ensure fire escape routes are kept clear and fire doors are always kept closed.
Regulation: Regulation 12(2)(b)
⚠ The service did not ensure systems and processes to mitigate risk including fire safety... were safe.
Must-do action 13 of 42
Must do
Safe
The trust must make sure equipment, such as resuscitation trolleys, are safe to use and checked daily to ensure they are in working order.
Regulation: Regulation 12(2)(e)
⚠ The service did not always make sure equipment, such as resuscitation trolleys, were accurately checked and safe to use.
Must-do action 14 of 42
Must do
Safe
The trust must ensure staff comply with infection control and prevention procedures when looking after patients with or suspected of having an infectious illness
Regulation: Regulation 12(2)(h)
⚠ The service did not always prevent infection risk well. Staff did not always use equipment and control measures to protect patients, themselves and others from infection.
Must-do action 15 of 42
Must do
Safe
The trust must ensure chemical products hazardous to health (COSHH) are stored safely and securely.
Regulation: Regulation 17(2)(b)
⚠ The service did not always ensure chemical products that are hazardous to health were stored safely and securely.
Must-do action 16 of 42
Must do
Safe
The trust must ensure there is a clinical pharmacy service across all medical wards, including escalation areas where medically fit patients reside.
Regulation: Regulation 12(2)(g)
⚠ Clinical pharmacy services and medicines storage was not always available on the escalation wards where medically fit patients resided.
Must-do action 17 of 42
Must do
Safe
The trust must ensure radiology staff use the World Health Organisation checklist before each radiology intervention
Regulation: Regulation 12 Safe Care and Treatment
Must-do action 18 of 42
Must do
Well-led
The trust must ensure all computer terminals are locked when not in use
Regulation: Regulation 17 Good governance
Must-do action 19 of 42
Must do
Safe
The trust must ensure fire extinguishers are maintained correctly
Regulation: Regulation 12 Safe Care and Treatment
Must-do action 20 of 42
Must do
Safe
The trust must ensure all boarded patients have had a full risk assessment prior to boarding
Regulation: Regulation 17 Good governance
⚠ Staff did not always complete patient risk assessments on admission to medical wards.
Must-do action 21 of 42
Must do
Safe
The trust must ensure all relevant staff are trained to the highest level of life support. This includes ensuring the Childrens Assessment Unit has a staff member on duty trained in Advanced Paediatric Life Support in line with the Royal College of Nursings safe staffing guidelines, which states, a Paediatric Assessment Unit should have Advanced Paediatric Life Support trained staff.
Regulation: Regulation 18(1)(2)(a): Staffing
⚠ Only 17% of medical staff had completed either European Paediatric Advanced Life Support (EPALS) or Advanced Paediatric Life Support (APLS). Furthermore, only 50% of nursing staff had completed this vital retraining within 4 years.
Must-do action 22 of 42
Must do
Safe
The trust must ensure staff training compliance rates for Resuscitation training level 2 and level 3 are in line with trust targets.
Regulation: Regulation 18(1)(2)(a) Staffing
⚠ Resuscitation training was also worse than the trust target with resuscitation Level 2 (paediatric hospital life support training) completed by only 39% of medical staff and 62% of nursing staff. Resuscitation Level 3 (paediatric intermediate life support) had slightly better compliance with 58% of medical staff completed and 83% of …
Must-do action 23 of 42
Must do
Safe
The trust must ensure medical staff are up to date with mandatory training in key skills. This includes safeguarding adults and children training to the appropriate level.
Regulation: Regulation 18(1)(2)(c) Staffing
⚠ Medical staff were 100% compliant with safeguarding training level 1 but were below trust targets for level 2 and 3 safeguarding training, where only 76% had completed training.
Must-do action 24 of 42
Must do
Safe
The trust must ensure all temporary staff are provided with an induction and are competent to work within a paediatric setting.
Regulation: Regulation 18(2)(a) Staffing
⚠ We asked an agency worker if they had completed an induction and they confirmed they had not. They had been working at the hospital for several weeks and had not completed an induction. We also spoke with a student nurse who had not completed an induction specific to the ward.
Must-do action 25 of 42
Must do
Safe
The trust must ensure all staff maintain effective oversight of patients for the duration of their care within the ED. For example, ensuring patients are regularly assessed and reassessed clinically.
Regulation: Regulation 12(1)(2)(a)(b): Safe care and treatment
⚠ Staff did not always identify and quickly acted upon patients at risk of deterioration.
Must-do action 26 of 42
Must do
Safe
The trust must ensure medical and nursing staff are up to date with mandatory training in key skills. This includes safeguarding adults and children training to the appropriate level.
Regulation: Regulation 18(1)(2)(c) Staffing
⚠ Staff had varied compliance with training in key skills. Safeguarding training was below trust targets for medical staff.
Must-do action 27 of 42
Must do
Caring
The trust must ensure patients are always treated with dignity and respect, including during medical and clinical assessments when in overcrowded areas.
Regulation: Regulation 10(1): Dignity and respect
⚠ Due to crowding and lack of space, assessments for these patients were carried out in the corridor next to the Rapid Assessment Treatment (RAT) area without any privacy and dignity.
Must-do action 28 of 42
Must do
Safe
The trust must ensure staff at all levels complete the necessary training to enable them to carry out the duties they are employed to perform.
Regulation: Regulation 18(2)(a)
⚠ The service did not ensure staff at all levels completed the necessary mandatory and statutory training to enable them to carry out the duties they are employed to perform.
Must-do action 29 of 42
Must do
Safe
The trust must ensure fire escape routes are kept clear and fire doors are kept closed.
Regulation: Regulation 12(2)(b)
⚠ There were a number of concerns around fire safety identified. For example, on Deal Ward, the narrow corridor was cluttered with equipment, such as computers on wheels and moving and handling equipment. This posed a fire hazard and would make it difficult to evacuate patients in such an event. Similarly, …
Must-do action 30 of 42
Must do
Safe
The trust must ensure staff follow infection control principles, including the use of Personal Protective Equipment.
Regulation: Regulation 12(2)(h)
⚠ Staff did not always follow infection control principles including the use of personal protective equipment (PPE).
Must-do action 31 of 42
Must do
Safe
The trust must make sure equipment, such as resuscitation trolleys, are safe to use and accurately checked daily to ensure they are in working order.
Regulation: Regulation 12(2)(e)
⚠ Staff did not always carry out daily safety check of specialist equipment. For example, on 1 ward we found ECG (electrocardiogram) electrodes on the emergency trolley were out of date and had not been removed, despite daily checks. On another ward, we found a resuscitation trolley unsecured on both days …
Must-do action 32 of 42
Must do
Safe
The trust must ensure chemicals that are hazardous to health (COSHH) are stored safely and securely.
Regulation: Regulation 17(2)(b)
⚠ Hazardous substances were not always stored safely and securely. On the AMU, we found chlorine tablets in the sluice area in an unlocked cupboard.
Must-do action 33 of 42
Must do
Safe
The trust must ensure they keep patient records secure.
Regulation: Regulation 17(2)(c)
⚠ Records were not always stored securely. Some staff did not comply with legislation to protect patient privacy and confidential information. While computers on wheels and notes trolleys were locked, we saw 8 folders with patient information in an unlocked area where anyone could view them.
Must-do action 34 of 42
Must do
Safe
The trust must ensure there is a clinical pharmacy service across all medical wards, including escalation areas where medically fit patients reside.
Regulation: Regulation 12(2)(g)
⚠ Clinical pharmacy services and medicines storage was not always available on the escalation wards where medically fit patients resided.
Must-do action 35 of 42
Must do
Safe
The trust must ensure the appropriate storage of medicines across all medical wards, including escalation areas where medically fit patients reside.
Regulation: Regulation 12(2)(g)
⚠ Staff could not always store and manage all medicines and prescribing documents in line with the provider’s policy. While medicines were stored and managed safely on general medical wards, appropriate medicines storage was not consistently available on escalation wards.
Must-do action 36 of 42
Must do
Safe
The trust must ensure staff training compliance rates for mandatory training are in line with the trust target.
Regulation: Regulation 18
⚠ The overall completion rate for mandatory training across all modules was 80% which was below the trust target of 91%.
Must-do action 37 of 42
Must do
Safe
The trust must ensure safeguarding training rates for medical staff are improved to the trust target.
Regulation: Regulation 18
⚠ The completion rate for safeguarding training for children at level 3 at the hospital was 55% for medical staff. The completion rate for safeguarding training in adults at level 2 was 49% overall for medical staff at the hospital. The trust could not be reasonably assured that medical staff had …
Must-do action 38 of 42
Must do
Safe
The trust must ensure the environment in the Special Care Baby Unit (SCBU) is kept at a suitable temperature.
Regulation: Regulation 15
⚠ Concerns were also found in the SCBU unit due to the temperature of the unit. Managers told us room temperatures were checked, and we saw records to support this. However, targets for maximum room temperatures were often exceeded and there were unclear records and an absence of policies associated with …
Must-do action 39 of 42
Must do
Safe
The trust must ensure suitable alternative arrangements for the delivery of SCBU services are documented in the child health risk register if the environment becomes unsuitable.
Regulation: Regulation 15
⚠ It was unclear what arrangements would occur if the SCBU environment became unsuitable. We did not see any alternative arrangements underpinned by policy and the area was not referenced in the child health risk register.
Must-do action 40 of 42
Must do
Safe
The trust must ensure cooling equipment for the SCBU is properly maintained, and risk assessed for Infection Prevention and Control and records are maintained to support this.
Regulation: Regulation 15
⚠ There was one concern however, found in the SCBU relating to air conditioners. These pieces of equipment had no maintenance checklists available to support their operation and unclear governance arrangements associated with who was responsible for them. It was unclear when the air conditioner’s filters were last changed and when …
Must-do action 41 of 42
Must do
Safe
The trust must ensure there are clear arrangements for patients in the SCBU if the environment becomes unsuitable due to uncontrolled temperatures.
Regulation: Regulation 17
⚠ It was unclear what arrangements would occur if the SCBU environment became unsuitable. We did not see any alternative arrangements underpinned by policy and the area was not referenced in the child health risk register.
Must-do action 42 of 42
Must do
Safe
The trust must ensure staff are referencing the same medicine formularies across the CYP departments.
Regulation: Regulation 17
⚠ Our medicine teams saw that medical staff and nursing prescribers used different medicine formularies and found one example where an ad-hoc dose of medicine was delayed when administered. We explored this and found that medical staff referenced one formulary which was promoted on the trust intranet, while nurse prescribers referenced …

Should-do actions (32)

Recommended improvements to enhance service quality.

Should-do action 1 of 32
Should do
Well-led
The trust should consider reviewing current staff engagement processes to ensure they are effective.
Should-do action 2 of 32
Should do
Well-led
The leadership team should consider how future leaders operationalise the vision and support continuation of work introduced by people in current interim roles.
Should-do action 3 of 32
Should do
Well-led
The trust should ensure the Freedom to Speak Up processes are sufficiently resourced to support staff to raise concerns.
Should-do action 4 of 32
Should do
Caring
The trust should ensure staff with long-term health conditions are protected in line with The Equality Act 2010 and have meaningful personal adaptation plans to ensure they are treated fairly, with dignity and respect they deserve.
Should-do action 5 of 32
Should do
Caring
The trust should ensure all staff are protected in line with Equality Act 2010, to ensure they are treated fairly, with dignity and respect they deserve.
Should-do action 6 of 32
Should do
Well-led
The trust should ensure it seeks and acts quickly on feedback from staff for the purposes of continually evaluating and improving services.
Should-do action 7 of 32
Should do
Safe
The trust should ensure all staff have regard to trust policy when reporting incidents and near misses.
Regulation: 17(2)(b) Good governance
Should-do action 8 of 32
Should do
Well-led
The trust should ensure staff are given regular appraisals.
Regulation: 18(1)(2)(a): Staffing
Should-do action 9 of 32
Should do
Safe
The trust should ensure patient equipment is maintained well and can be cleaned in between patient use.
Should-do action 10 of 32
Should do
Safe
The trust should ensure ward areas are always tidy and clutter-free.
Should-do action 11 of 32
Should do
Caring
The trust should ensure patient call bells are answered promptly.
Should-do action 12 of 32
Should do
Well-led
The trust should ensure audits are accurate so they can be used to drive improvements in the service.
Should-do action 13 of 32
Should do
Safe
The trust should ensure staff working under their enhanced observation framework are given suitable rest periods in line with their policy.
Regulation: Regulation 18(2)(a): Staffing
Should-do action 14 of 32
Should do
Well-led
The trust should ensure staff are given regular appraisals.
Regulation: 18(1)(2)(a): Staffing
Should-do action 15 of 32
Should do
Effective
The trust should ensure staff receive appropriate ongoing or periodic supervision in their role to make sure competence is maintained.
Regulation: 18(2)(a): Staffing
Should-do action 16 of 32
Should do
Responsive
The trust should consider introducing education facilities for children staying on wards.
Regulation: Regulation 9(1): Person-centred care
Should-do action 17 of 32
Should do
Effective
The trust should ensure a suitable paediatric trained physiotherapist is available for children.
Regulation: 9(1): Person-centred care
Should-do action 18 of 32
Should do
Well-led
The trust should consider how Information is analysed and reviewed and its significance is understood. For example, how results should be escalated, and appropriate action taken.
Regulation: 17(2)(b): Good governance
Should-do action 19 of 32
Should do
Safe
The trust should ensure all staff have regard to trust policy when reporting incidents and near misses.
Regulation: 17(2)(b): Good governance
Should-do action 20 of 32
Should do
Well-led
The trust should ensure staff are given regular appraisals.
Regulation: 18(1)(2)(a): Staffing
Should-do action 21 of 32
Should do
Effective
The trust should ensure Allied Health Professionals have access to enough space in the hospital to conduct patient assessments.
Should-do action 22 of 32
Should do
Effective
The trust should ensure they have enough Allied Health Professionals available to provide care to patients on medical wards, including those in escalation areas where medically fit patients reside.
Should-do action 23 of 32
Should do
Responsive
The trust should ensure they make efforts to reduce the number of times patients are moved from one ward to another, and to avoid moving patients outside of regular working hours.
Should-do action 24 of 32
Should do
Safe
The trust should ensure all risk assessments on patients are completed on admission to medical wards.
Should-do action 25 of 32
Should do
Safe
The trust should ensure they follow their Standard Operating Procedure when placing patients in escalation areas.
Should-do action 26 of 32
Should do
Safe
The trust should ensure they have systems and processes in place to ensure all incidents, regardless of whether they result in harm, are reported.
Should-do action 27 of 32
Should do
Safe
The trust should ensure ligature risk is reassessed and added to the risk register for the paediatric emergency department.
Should-do action 28 of 32
Should do
Safe
The trust should ensure a risk assessment is completed for the play area of the ward.
Should-do action 29 of 32
Should do
Safe
The trust should ensure staff working under their enhanced observation framework are given suitable rest periods in line with their policy.
Should-do action 30 of 32
Should do
Well-led
The trust should ensure medical staff appraisal rates are improved.
Should-do action 31 of 32
Should do
Well-led
The trust should consider systems and processes which support managers own oversight of training completion rates and renewal dates held centrally by the trust governance team.
Should-do action 32 of 32
Should do
Responsive
The trust should consider an audit process associated with why patients were transferred between CYP environments.

Location details

CQC ID: RVV09
Local authority: Kent
Region: South East

Inspection report

Type: Location
Date: 20 December 2023
Rating: Requires Improvement
Actions: 42 must-do 32 should-do
AI-extracted 3 Jun 2026

Related PFD reports

2025-0579 — Ernest Gray (Nov 2025)
2026-0010 — Sarah Heaver (Sep 2025)
2025-0308 — Upali Meththananda (Jun 2025)
2025-0335 — Ann Caldicott (Jun 2025)
2024-0518 — Megan Williams (Sep 2024)
2023-0509 — Jasbir Pahal (Dec 2023)
2022-0338 — Keith Dimond (Oct 2022)
2022-0064 — Neil Hickman (Feb 2022)
2022-0060 — Christopher Osland (Feb 2022)
2022-0402 — Hadley Savory (Aug 2021)