Our rating of services stayed the same. We rated it them as requires improvement because:

• We found some improvement had been made since the planned March 2017 inspection but more work was needed to bring about the substantial improvement that was required.
• However, some of the improvements were too recent to assess their effectiveness and in critical care we found improvements made following the March 2017 inspection had not been sustained.
• The emergency department (ED) was, at times, overcrowded and patients were cared for in corridors with screens used to try and maintain privacy and dignity for patients. Managing demand and capacity had been a long standing problem for the hospital.
• In critical care privacy and dignity was sometimes compromised as the beds were very close to each other.
• There were staffing shortages, medical, nursing and allied health professionals, in most of the services we inspected. Consultant cover in the ED and critical care was not in line with national guidance.
• The uptake of appraisals and completion of mandatory training was variable and did not always meet the trust target. This was a particular problem for medical staff.
• Shortages of nursing staff were impacting on the effectiveness of end of life care and it was not a seven day service.
• We found problems with the management of medicines in surgery, ED and critical care.
• In the emergency department staff were not aware of the all the policies related to the care of patients with mental health needs and the hospital did not have a clear pathway for patients attending the ED with known or suspected mental health issues
• Some policies in surgery and critical care were past their review date and/or not dated.
• The hospital had not always met the 62-day referral to treatment target for patients with cancer.
• In most services we inspected we found delays in responding to complaints.
• Services we inspected had systems to monitor the quality and safety of care provided but in surgery medical staff were not fully engaged in improvement projects or the quality agenda.

However:

• Some action had been taken following previous inspections with some improvements maintained.
• The profile and leadership of end of life care had improved and we found some action had been taken to improve patient care along with systems for reviewing and improving the quality and safety of the service.
• Maternity services had maintained its rating of good and we found good cross site working.
• Systems to ensure patient safety in the emergency department had been established and there were plans to reduce the overcrowding with the establishment of the clinical decision unit.
• The day care unit was no longer used to care for patients when beds on the appropriate ward were not available and there was improved compliance with the spinal trauma pathway.
• In critical care patients who had previously been transferred to another hospital for some procedures were now able to be treated at QEH.
• We found staff were caring and compassionate and we observed positive interactions between patients and staff.
• In most services we inspected staff were positive about their immediate line manager and felt they were supportive and approachable.
• The divisions were undergoing a restructure at the time of the inspection with the aim of strengthening leadership and devolving decision making.