Updated 28 March 2024
Doncaster and Bassetlaw Teaching NHS Foundation Trust provides acute services for 420,000 across South Yorkshire, North Nottinghamshire, and the surrounding areas. The trust employs over 6000 staff.
The trust has over 8000 members and was one of the first ten trusts to achieve foundation status, which was awarded in 2004. The trust received teaching status in 2017 and trains approximately 25% of medical students and 30% of all other healthcare professional students in the trust’s catchment area. The trust has four locations where services are provided:
- Bassetlaw District General Hospital
- Doncaster Royal Infirmary
- Montagu Hospital, Mexborough
- Retford Hospital
We carried out this unannounced inspection of 4 acute core services across 3 locations provided by this trust on 22-24 August 2023 and diagnostic imaging across 4 locations on 26-28 September 2023. We undertook this inspection because we had concerns about the quality of services. We also inspected the well-led key question for the trust overall on 2-4 October 2023.
We inspected urgent and emergency care services, medical wards, surgical wards, diagnostic imaging and maternity services at Bassetlaw District General Hospital and Doncaster Royal Infirmary. We inspected urgent and emergency care services, medical wards and diagnostic imaging at Montagu Hospital, Mexborough. We also inspected diagnostic imaging at Retford Hospital.
Our rating of services went down. We rated them as requires improvement because:
We rated safe, effective, responsive, and well led as requires improvement. We rated caring as good.
In rating the trust, we considered the current ratings of the services we did not inspect this time.
The trust leadership team showed adequate experience and knowledge to lead the trust. The leadership team was newly formed with some recent key appointments. There was further work needed to ensure the Board was cohesive and unitary. They understood the priorities and issues the trust faced however there were several recent changes to organisational structures which would take time to embed.
The trust had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. Some enabling strategies were under review and newly developed.
Not all staff felt leaders were visible. Staff in areas where there were greater pressures, due to challenges recruiting staff, financial restraints, and patient demand, felt less supported by the senior leadership. There was further work to do to ensure all staff felt safe to speak up and to ensure the Board was effectively sighted on concerns raised by staff.
There were areas identified for improvement in governance frameworks and controls. There were areas of risk where assurance processes were not effective, and work was continuing to develop these. During our inspection we escalated several concerns regarding equipment, cleanliness, and management of medicines which the trust responded to and acted.
The trust collected data and analysed it however systems and processes were newly implemented and required further work to ensure the Board was fully sighted on key risks presented in the data.
Leaders and staff engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They worked with partner organisations to help improve services for patients.
The trust understood quality improvement methods and the skills to use them however some quality improvement priorities had not been achieved and were yet to be fully embedded.
How we carried out the inspection
The inspections of the trust’s core services were led by a CQC operations manager and supported by eight CQC inspectors, one CQC regulatory officer, a CQC inspection planner and eight specialist professional advisors.
The inspection of the well-led key question (the trust’s senior leadership and governance) was led by a CQC Deputy Director of Operations and supported by an operations manager, one CQC inspector, one CQC regulatory officer and an inspection planner. The team also received support from four specialist professional advisors and executive reviewers with a background and experience in NHS senior management.
You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.