Queen Mary's Hospital

Updated 28 March 2018

This hospital provides only low risk surgery services. See below for more information.

Updated 28 March 2018

We have not rated this hospital before. We rated it as good because:

• It provides only surgery services, which we rated as good.

Updated 28 March 2018

We rated it as good because:

• Staffing on the day of our inspection was sufficient to meet the needs of the patients.
• Patients and relatives told us they felt involved in decisions about their or their loved-ones care and treatment.
• The service contributed to the national joint register for joint replacement surgery.
• There was good multidisciplinary working within different speciality surgery services. Access to the multidisciplinary workforce was sufficient to meet the needs of patients.
• All staff had received annual appraisals.
• Patient’s pain was assessed and managed effectively. There was access to anaesthetists who provided support regrading pain management.
• We saw staff were caring and compassionate to patients’ needs.
• There was evidence of learning from incidents and staff said they received feedback regarding incidents.
• There were effective infection control and prevention practices in place. We observed good adherence to trust infection control policies and national guidance.
• Records were complete, well managed and stored securely.
• Patient feedback was continually positive about staff and the care they received. Patients we spoke to had undergone treatment on multiple occasions at the hospital and were overwhelmingly positive about the care they received.

However:

• The World Health Organisation safer surgery checklist were not consistently used effectively. Despite a never event we found nine out of 10 World Health Organisation safer surgery checklists were incomplete.
• There was not a process which ensured ad-hoc agency theatre staff had the skills knowledge and qualifications to perform their role. When agency staff were requested at short notice managers did not have assurance that they had all the correct pre-employments checks undertaken, were qualified and had the skills and knowledge required to perform their role.
• Safety checks on anaesthetic machines were inconsistently undertaken.
• Patients’ confidentiality, dignity and respect was not maintained within the theatre holding bay.
• Compliance mental capacity act training was poor. This meant staff may not have awareness if patients lacked mental capacity to make decisions; or understand best interests decisions or awareness of the Mental Capacity Act 2005.
• There were not established procedures and practices in place for invasive procedures.