Source · CQC inspection

Queen's Medical Centre

Provider Nottingham University Hospitals NHS Trust Type NHS Healthcare Organisation Region East Midlands Last inspected 4 Mar 2026

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.

Not Yet Rated Assessed 13 May 2026
On 18 February 2026 we inspected the Queens Medical Centre maternity unit, part of Nottingham University Hospitals NHS Trust. We undertook a focused inspection to review progress to enforcement action that we had undertaken following our previous inspection in May 2025. We found that some improvements had been made and whilst concerns had been addressed the underpinning actions were not robust. This included the procedures for reducing the risk of babies being abducted and the support of staff.

Ratings by service

Maternity
Requires Improvement
Mar 2026
Maternity
Requires Improvement
Feb 2025
Maternity
Requires Improvement
Jun 2024

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 (4)

Breach Safe
We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in the following areas: Safe care and treatment – in relation to medicines management and the security.
Regulation: Regulation 12 (Safe care and treatment) · 4 Mar 2026
Breach Well-led
We found breaches of regulations relating to security; organisational culture, staff well-being; engagement; visibility of leadership; consultant staffing and safeguarding training requirements.
Regulation: Regulation 18 (Staffing) · 4 Mar 2026
Breach Safe
We identified 3 breaches of regulation in safe care and treatment.
Regulation: Regulation 12 (Safe care and treatment) · 18 Feb 2025
Breach Safe
We identified 3 breaches in safe care and treatment.
Regulation: Regulation 12 (Safe care and treatment) · 28 Nov 2024

Earlier inspection findings

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

Must-do actions (10)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 10
Must do
Well-led
The trust must ensure that it complies with its statutory responsibilities for duty of candour.
Regulation: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3). Regulation 20: Duty of candour.
⚠ The trust was not always complying with its statutory responsibilities for duty of candour.
Must-do action 2 of 10
Must do
Safe
The trust must ensure expressed breast milk is stored safely and in line with national guidance.
Regulation: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3). Regulation 12: Safe care and treatment.
⚠ On Lawrence ward and Bonington ward we saw they had milk kitchens where formula milk was stored for women who decided to provide this for their baby. The milk kitchens also stored expressed breast milk for women who were breast feeding their babies. This was labelled to ensure there were …
Must-do action 3 of 10
Must do
Safe
The trust must follow appropriate guidance in the proper and safe storage and administration of medicines, including ensuring fridge temperatures are monitored, recorded and out of range temperatures escalated in line with trust requirements.
Regulation: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3). Regulation 12: Safe care and treatment.
⚠ We also found that the room temperature where medicines were stored on the labour ward was consistently above the required range and there had been no action to rectify this. This was raised with staff at the time who told us that it did not affect the efficacy of the …
Must-do action 4 of 10
Must do
Well-led
The trust must ensure there is an effective risk and governance system in place that supports safe quality care for all areas in the service, mitigates risks when identified, and is in line with the conditions placed upon their registration.
Regulation: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3). Regulation 17: Good governance.
⚠ We had identified some improvements to the governance process, but we found there was a lack of oversight within the current governance structure for the management of certain performance metrics. For example, data around the management of electronic observation audits remained low. We had served the trust a warning notice …
Must-do action 5 of 10
Must do
Safe
The trust must ensure expressed breast milk is stored safely and in line with national guidance.
Regulation: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3). Regulation 12: Safe care and treatment.
⚠ Expressed breast milk was labelled but stored in a refrigerator in an unlocked room accessible to all. Staff signed them out but the storage was unsafe and not in line with national guidance. There was a risk that unauthorised individuals could tamper with the breast milk. We raised this during …
Must-do action 6 of 10
Must do
Safe
The trust must follow appropriate guidance in the proper and safe storage and administration of medicines, including ensuring fridge temperatures are monitored, recorded and out of range temperatures escalated in line with trust requirements.
Regulation: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3). Regulation 12: Safe care and treatment.
⚠ Fridge temperature checks for the breast milk fridge were consistently done but out of range with zero degrees recorded on over 7 days in April 2023. This had not been escalated. The trust’s own sheet used to record fridge temperatures stated that the fridge temperature should range from 2 to …
Must-do action 7 of 10
Must do
Safe
The trust must ensure safe use of disposable curtains to ensure the reduction of the risk of, and preventing, detecting and controlling the spread of, infections, including those that are healthcare associated;
Regulation: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3). Regulation 12: Safe care and treatment.
⚠ We saw single use curtains were used in the triage suite. They were visibly clean with no blood or body substances, dust, dirt, debris, stains or spillages. However, they were not dated, so it was unclear how long they had been hung, or when they were due to be changed. …
Must-do action 8 of 10
Must do
Safe
The trust must ensure call bell systems are well maintained to keep women and their babies safe.
Regulation: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3). Regulation 12: Safe care and treatment.
⚠ Emergency call bells were not always audible on B26 (antenatal ward), and staff had escalated this issue. A failure of the call bell system was declared in November 2022 following 3 incident reports in September 2022. As a mitigation, a temporary call bell separate panel to alert staff was installed …
Must-do action 9 of 10
Must do
Safe
The trust must ensure staff carry out risk assessments to keep women, their babies and staff safe from potential abuse.
Regulation: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3). Regulation 13: Safeguarding service users from abuse and improper treatment.
⚠ We were made aware of a safeguarding issue which required staff to protect women, babies and staff from potential abuse during our inspection. We saw no risk assessments at the time of our inspection. Following our inspection, we requested the provider’s assessment and management of individuals who pose a risk …
Must-do action 10 of 10
Must do
Well-led
The trust must ensure there is an effective risk and governance system in place that supports safe quality care for all areas in the service, mitigates risks when identified, and is in line with the conditions placed upon their registration.
Regulation: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3). Regulation 17: Good governance.
⚠ We had identified some improvements to the governance process, but we found there was a lack of oversight within the current governance structure for the management of certain performance metrix. For example, data around the management of electronic observation audits remained low. We had served the trust a warning notice …

Should-do actions (10)

Recommended improvements to enhance service quality.

Should-do action 1 of 10
Should do
Well-led
The trust should ensure arrangements for identifying risks, issues and mitigating actions are embedded.
Should-do action 2 of 10
Should do
Safe
The trust should ensure that all staff receive mandatory training to enable them to recognise, report abuse and provide safe and effective care to women and babies.
Should-do action 3 of 10
Should do
Effective
The trust should ensure carbon monoxide testing is offered to all pregnant women at antenatal booking appointment and at 36 weeks.
Should-do action 4 of 10
Should do
Safe
The trust should ensure accurate systems are in place to ensure comprehensive recording of venous thromboembolism risk assessments.
Should-do action 5 of 10
Should do
Effective
The trust should ensure all staff receive appraisal for their work performance.
Should-do action 6 of 10
Should do
Safe
The trust should ensure that all staff receive mandatory training to enable them to recognise, report abuse and provide safe and effective care to women and babies.
Should-do action 7 of 10
Should do
Safe
The trust should ensure that weights are recorded on medicines charts.
Should-do action 8 of 10
Should do
Effective
The trust should ensure carbon monoxide testing is offered to all pregnant women at antenatal booking appointment and at 36 weeks.
Should-do action 9 of 10
Should do
Safe
The trust should ensure accurate systems are in place to ensure comprehensive recording of venous thromboembolism risk assessments.
Should-do action 10 of 10
Should do
Effective
The trust should ensure all staff receive appraisal for their work performance.

Location details

CQC ID: RX1RA
Local authority: Nottingham
Region: East Midlands

Inspection report

Type: Location
Date: 13 September 2023
Rating: Requires Improvement
Actions: 10 must-do 10 should-do
AI-extracted 3 Jun 2026