• The trust had not taken all action to mitigate risks to patients. Staff were not adhering to their own guidance and national guidance regarding checking patients prior to procedures and counting instruments and swabs at the end of a procedure.
• Staff did not always comply with infection prevention and control best practice. Some staff did not wash their hands between patients.
• Learning from incidents was not consistent across services.
• Records were not always stored securely and the uptake of mandatory training was below the trust target.
• Awareness of how to recognise actual and potential signs of abuse was variable.
• Knowledge and awareness among staff about the Mental Capacity Act 2005 and how to apply it in practice was limited across services.
• Some policies and procedures had not been reviewed and updated.
• Local audit to monitor the quality and performance services provided and compliance with best practice was limited along with action plans following audits which had been completed.
• Patients were not always kept informed about delays with their outpatient appointment.
• The trust was not reporting referral to treatment times.
• Some clinics had long waiting times and staff were not recording and monitoring how long patients were waiting.
• The effectiveness of local leadership varied. Although there was a senior leadership team for QMH the senior nurse in outpatients was clearly a key person whom most people sought advice and help from. Senior leaders from the directorates, based at St George’s Hospital, were not so visible and some of them acknowledged this during our inspection.
• There was some governance activity but, some staff at QMH were not actively involved. Governance was led by individual directorates and directorate senior staff were mainly based at St George’s Hospital. Much of the activity was driven and led by St George’s Hospital with little focus on the specific needs of QMH.
• Senior nursing staff were available to support staff but, we found there was a lack of oversight of some services and opportunity for staff meetings where the quality and safety of the service could be reviewed and discussed. This meant that some risks, as found during this inspection, were not always identified and action taken.
• There was a sense of isolation and lack of specific professional support among staff at QMH and this was evidenced in the limited visibility of specialist/lead nurses/freedom to speak up guardian who rarely visited the hospital.

However:

• The endoscopy decontamination met national standards of good practice.
• Some staff were aware of the Duty of candour.
• Services were providing evidence-based care.
• We found action had been taken to improve the timeliness of reporting results and reduce waiting time for some services.
• Patients spoke positively about the care they received.
• We observed staff providing emotional support and reassurance before and after procedures.
• Staff maintained patient’s privacy and dignity and kept them informed about their care and treatment.
• Additional clinics were made available when demand was high to reduce delays in patients having their consultation.
• Consideration of the needs of children attending the hospital were taken into account with dedicated play areas in the outpatient clinics.
• Staff spoke positively about their local managers and the support they received from them.