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Bassetlaw District General Hospital Requires improvement

We are carrying out checks at Bassetlaw District General Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 23 October 2015

Bassetlaw District General Hospital was one of the acute hospitals forming part of Doncaster and Bassetlaw NHS Foundation Trust. The trust served a population of around 420,000 people in the areas covered by Doncaster Metropolitan Borough Council and Bassetlaw District Council, as well as parts of North Derbyshire, Barnsley, Rotherham, and north-west Lincolnshire.

Bassetlaw District General Hospital provided a range of services including medical, surgical, maternity and gynaecology, services for children and young people, end of life and critical care. It had approximately 300 beds. The hospital also provided emergency and urgent care and outpatients and diagnostic imaging.

We inspected Bassetlaw District General Hospital as part of the comprehensive inspection of Doncaster and Bassetlaw NHS Foundation Trust. We inspected the hospital site on 16 and 29 April 2015.

Overall, we rated Bassetlaw District General Hospital as requires improvement. We rated it good for being caring and well-led and requires improvement for responsive, effective and safe care.

Our key findings were as follows:

  • We found that most areas at the hospital were visibly clean. However, the theatre sterile supply unit was found to have some areas that required cleaning.
  • Staffing levels were reviewed and monitored. There were some areas of the trust particularly in children’s services and medicine that were not adequately staffed. We found this had an impact on patient care.
  • Patients were assessed for their nutritional and hydration needs and referred to a dietician if required.
  • There was a lack of medical staff with the appropriate qualification as set out in the core standards for intensive care units. That is a consultant who is a Fellow/Associate Fellow or eligible to become a Fellow/Associate Fellow of the Faculty of Intensive Care Medicine.
  • The Summary Hospital-level Mortality Indicator (SHMI) (1 July2013 to 30 June 2014) showed no evidence of risk. The Hospital Standardised Mortality Ratio indicator (1 July 2013 to 30 June 2014) showed an elevated risk.
  • Records indicated compliance with mandatory training and appraisal rates were generally low across the services.
  • Within diagnostic imaging, there were some doors with no signage that had unrestricted entry to x-ray controlled areas.

We saw several areas of outstanding practice including:

  • The staff support and training packages provided by the clinical educators in all areas where children and young people were seen in the trust

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • The trust must review nurse staffing of the children’s inpatient wards to ensure there are adequate numbers of registered children’s nurses and medical staff available at all times to meet the needs of children, young people and parents.
  • The trust must ensure that the public are protected from unnecessary radiation exposure.
  • The trust must ensure that staff receive mandatory training.
  • The trust must ensure that staff receive an effective appraisal.
  • The trust must ensure that a clean and appropriate environment is maintained throughout the theatre sterile supply unit that facilitates the prevention and control of infection.

In addition the trust should:

  • The trust should reduce patient waiting times to meet the 95% target for patients seen within four hours.
  • The trust should review access to equipment in the emergency department.
  • The trust should continue to take steps to support and develop working arrangements between the emergency department and other specialities within the trust.
  • The trust should record and monitor daily temperatures of fridges used for storage of medicines.
  • The trust should review engagement of medical staff with training, particularly in Mental Capacity Act and emergency planning.
  • The trust should review monitoring procedures to record where and why a breach of mixed sex accommodation has occurred and actions taken to avoid a repeat.
  • The trust should review the pain evaluation tool incorporated within the NEWS score observations to measure the pain experienced by patients
  • The trust should consider the use of a staffing needs acuity tool to record staffing needs more accurately and on a more frequent basis.
  • The trust should continue to review staffing on ward C1.
  • The trust should review the how toilet facilities can be improved on the cardiology ward to ensure separate designated facilities are maintained for men and women.

  • The trust should ensure that they follow best practice in terms of medical staff with appropriate intensive care qualifications.
  • The trust needs to ensure that there is appropriate out of hours cover for the critical care unit and that any risks associated with cross cover of services is mitigated.
  • The trust should ensure that appropriate delirium and sedation scores are undertaken and recorded.
  • The trust should ensure that appropriate access is available from supporting clinical services where required, including pharmacy, dietetics and the ear, nose and throat departments. 
  • The trust should review maintenance and deep cleaning schedules.
  • The trust should review documentation of wastage of Controlled Drugs (CD) on delivery suite.
  • The trust should review the provision of the service available from the teenage pregnancy midwife and substance misuse midwife at the hospital.
  • The trust should consider employing a specialist diabetes midwife.
  • The trust should review 24 hour availability of an obstetric anaesthetist.
  • The trust should make sure front line staff are aware of their responsibilities in relation to MCA and DOLS.
  • The trust should review the individual risk assessment tools with in the children’s service. For example, the service should ensure the initial nursing assessment includes nutritional status and nutritional risk assessments.
  • The trust should identify a board level director who can promote children’s rights and views. This role should be separate from the executive safeguarding lead for children.
  • The trust should agree a system for recording mental capacity assessments for patient’s unable to be involved in discussions about DNACPR decision
  • The trust should make available appropriate equipment for the care of bariatric patients after death.
  • The trust should review equity of access to palliative and end of life care services across both Bassetlaw DGH and Doncaster Royal Infirmary.
  • The trust should identify clear systems and processes to evidence post incident feedback, shared learning and changes in practice resulting from incidents.
  • The trust should review the audit programme in outpatients and diagnostics to monitor the effectiveness of services.
  • The trust should continue improvements to meet the 6 week target referral to treatment target for medical imaging.
  • The trust should review the processes for identifying and managing patients requiring a review or follow-up appointment.
  • The trust should further develop the outpatient’s services strategy to include effective service delivery.
  • The trust should identify and monitor key performance indicators for outpatients.
  • The trust should implement plans to ensure radiology discrepancy and peer review meetings are consistent with the Royal College of Radiology (RCR) Standards.
  • The trust should consider auditing the call bells within the diagnostic imaging departments.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas


Requires improvement

Updated 23 October 2015


Requires improvement

Updated 23 October 2015



Updated 23 October 2015


Requires improvement

Updated 23 October 2015



Updated 23 October 2015

Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 23 October 2015

There is a legal requirement to protect the public from unnecessary radiation exposure. We saw that there were some doors with no signage that had unrestricted entry to x-ray controlled areas. This was raised with the trust and referred to the Health and Safety Executive. There were effective systems to report incidents. However, in some areas we were unable to identify clear systems and processes to evidence post incident feedback, shared learning and changes in practice resulting from incidents.

The percentage of staff that had undertaken mandatory training and received an annual appraisal was well below the trust compliance target of 85%, particularly within outpatients departments. It was unclear if this was a recording issue, but meant the trust could not be assured staff had the necessary training.

Paediatric resuscitation equipment was contained within the adult trolleys within the CT and main radiology department. Staff were unaware of this which posed a potential risk. We saw patient personal information and medical records were mostly managed safely and securely. Evidence-based guidance was available however there was limited evidence of audit to demonstrate effectiveness. This included IR(ME)R related audits.

All of the patients we spoke with across the department told us they were very happy with the services provided.

The management team were in the process of reviewing capacity and demand for outpatient clinics and recognised the need to address the rate of clinic cancellations by the hospital. Trust-wide data showed 16.8% of patients waited more than 30 minutes to be seen. Most referral to treatment targets were met including all cancer related targets. Medical imaging was not meeting the 6 week target referral to treatment target; however improvements had been made.

There was no centrally held list of all patients requiring a review or follow-up appointment.

An outpatient’s services strategy had been drafted in December 2014. However, this lacked detail. A review of outpatient services had started to audit the current outpatient service delivery and clinical work streams but this was not yet completed. There were limited key performance indicators for outpatients. Radiology discrepancy and peer review meetings were inconsistent with the Royal College of Radiology (RCR) Standards.

Maternity and gynaecology

Requires improvement

Updated 23 October 2015

Overall, maternity and gynaecology services required improvement. Systems were in place for reporting, investigating and acting on adverse events. There had been two clusters of stillbirths from January 2014 to January 2015. A still birth review had taken place and each case was assessed against the National Patient Safety Agency Stillbirth Toolkit. The action plan was due for completion shortly after our visit.

Midwifery staffing ratios were in line with the national recommended ratio of 1:28. Consultant cover at Bassetlaw maternity unit was 40 hours per week in line with the number of babies delivered on the unit per year. There was no dedicated emergency obstetric theatre team at Bassetlaw hospital during the mornings on weekdays. An emergency team was available at all other times. High rates of sickness were evident on the gynaecology ward.

Completion of mandatory training was at a good level for midwives, midwifery support workers and health care assistants. Mandatory training participation for medical staff was poor. There was a range of specialist midwives in post however neither the teenage pregnancy special midwife nor the substance- misuse specialist midwife had input into vulnerable women at Bassetlaw hospital. There was no specialist diabetes midwife in post. Good evidence of safeguarding vulnerable women was evident. There was limited awareness of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).

On the labour ward there was no documentation evidence of wastage of controlled drugs used in epidural procedures.

Normal births were promoted. Since 2010 there had been a high percentage of non-elective neonatal readmissions within 28 days of birth. An action plan was in place and was being monitored. There were no designated scanning facilities in the EPAU at Bassetlaw; women had to go to the Ultrasound department with other ‘general’ users of the service. Maternity and nursing staff were caring. Patients and women spoke positively about their treatment by clinical staff and the standard of care they had received. There was good evidence of individualised maternity care. Hypnobirthing was available on delivery suite.

We found there was disconnection between ward staff and the board. Most staff were unaware of the vision for the service. We observed strong team working, with medical staff, nurses and midwives working cooperatively and with respect for each other’s roles. They told us that Bassetlaw was a ‘good place to work’. Most staff we spoke with were positive and enthusiastic.

Medical care (including older people’s care)


Updated 23 October 2015

We rated medical care services as good for effective, caring, responsive and well led. The safe domain required improvement.

During our inspection we witnessed most staff behaving in a caring and respectful manner towards their patients. Patient buzzers were answered promptly in most areas visited. There was a wide range of national and local audit activity undertaken at Bassetlaw District General Hospital including the trust-wide quality metrics audit framework for ward managers to complete (Ward Quality Assessment Tool). Where required, actions were taken in response to audit outcomes, for example the National Diabetes Inpatient Audit (2013) resulted in strengthening the trust wide clinical resource to support staff in managing diabetes effectively.

On the day of inspection, nurse staffing levels on the respiratory medicine ward (C1) were planned to be four trained nurses during the day and evening shift and three at night. The actual staffing level was three trained nurses on the day and evening shift and two trained nurses at night resulting in a ratio of 14 patients to one trained nurse overnight. We noted that 21 incident reports had been submitted recording staff shortages on C1 between September and December 2014. All were graded as no harm caused; however the reports include reference to medicines not being given on time as well as repositioning of patients, assessment scores and observations not being carried out on a timely basis. Wards A4 and A5 also submitted incident reports about staffing shortages impacting on the standard of care including lack of timely repositioning of patients and managing wandering and confused patients.

Staff were generally positive about the leadership and the levels of engagement with their line management through to executive level. However junior staff in less well staffed areas voiced less confidence in the leadership and expressed low morale due to the on-going workload pressures experienced on the wards. The impact of the staffing shortages on C1 was evident through documentation in case notes and the incident reporting system. On our unannounced inspection on 29 April 2015, we found that the staffing levels had been reviewed and four beds had been closed. Staff reported this action had a positive impact and they were able to deliver care to meet patients’ needs.

On the day of inspection, both bays on the cardiology ward had mixed sex accommodation but in each bay there was a female patient who was no longer on cardiac monitoring. The hospital policy stated that this was not acceptable when “the patient no longer needed Level 2 or Level 3 care and was awaiting a bed on an appropriate ward.” The mixed sex accommodation trust policy was discussed with the ward manager and Matron and immediate action was taken to move the two female patients at the earliest opportunity. An email with the policy attached was sent to all members of the cardiology medical and nursing teams to clarify the requirement to move patients once there was no applicable clinical need to keep them in mixed sex accommodation. We revisited this area as part of our unannounced inspection. We found the policy was implemented; there were no mixed sex breaches.


Urgent and emergency services (A&E)

Requires improvement

Updated 23 October 2015

There were not enough nurses trained to care for children to provide a nurse on each shift. The shortage of medical staff in the emergency department reflected the national picture. Mandatory training was not up to date within the emergency department. There was no formal major incident awareness or training provided for medical staffing. Medical staff demonstrated poor application of the MCA and of DoLs procedures.

Concerns were raised by staff at the non-availability of an ultrasound machine to perform FAST scans. The standard of cleanliness was variable and affected by the building work being undertaken to increase the capacity on Clinical Decisions Unit. The monitoring of fridge temperatures was intermittent.

The 95% target for patients seen within four hours had not been consistently maintained at Bassetlaw hospital. 

An initial clinical assessment of patients was undertaken using a recognised tool. Investigation of incidents was undertaken and there was evidence of lessons learned. Nursing staff were aware of their responsibilities under the duty of candour requirements, however medical staff were not.

Systems were in place to safeguard vulnerable adults and children.

The department used National Institute of Clinical Excellence (NICE) and College of Emergency Medicine (CEM) guidelines to support the treatment provided for patients. The emergency department contributed to a range of CEM audits which demonstrated a mix of good and poor results. Action plans had been prepared to address variable performance.

There was proactive working with the Acute Treatment Centre. However, there was limited interchange with some specialities.

Patients were cared for with empathy and with respect to their dignity on most occasions. We did observe that patients were transferred to trollies in the corridor in a way which potentially compromised the dignity of patients.

The emergency care group operational plan for 2015-17 and the five year plan the trust had developed involved a significant re-organisation of the structure of the emergency department. Senior staff spoke positively about the new leadership team. There was an open culture in the emergency department.



Updated 23 October 2015

We found that surgical services were safe. However, staff in the main operating theatres told us there were no pre-planned maintenance and deep cleaning schedules. We also found that the theatres’ sterile supply room had not been adequately cleaned.

We found that surgical services were effective although we had concerns about the level of mandatory training, with the service not meeting the trust target that 85% of all staff should have received mandatory training.

We found that the service was caring, responsive and well-led. Patient access and flow compliance with the ‘referral to treatment’ (RTT) targets were affected by the numbers of medical patients admitted to surgical wards.

Intensive/critical care


Updated 23 October 2015

Overall critical care services at Bassetlaw District General Hospital were judged as good.

Within safety, concerns were identified with regard to the lack of pharmacy staff cover, there were no specifically trained intensivists working within the unit, and there was a lack of dedicated medical out of hours cover provided on the unit. We also identified concerns regarding a lack of delirium and sedation scoring and recording in patient records. However we did not identify any specific concerns regarding the levels of nursing staff on the unit, but some staff did comment that they were often moved to the critical care unit at Doncaster Royal Infirmary.

There were, however, many positive aspects to the unit. Caring was good, patients stated they were well cared for and surveys supported this. Care was effectively delivered by the multidisciplinary team utilising best practice. The service was well led locally, though as a relatively new care group unit, further focus was required on the development of the unit and its future use and links to the unit at Doncaster Royal Infirmary.

Services for children & young people


Updated 23 October 2015

Overall we rated effective, caring, responsive and well-led as good. We rated safe as requires improvement.

The service followed evidenced-based best practice guidance and participated in appropriate national and local audits. Children and young people had access to appropriate pain relief. Staff were competent to carry out their roles and received appropriate professional development. There was good multidisciplinary working within and between teams and children and families were provided with appropriate information. Consent procedures were in place and were followed.

Children, young people and family members told us they received supportive care and staff kept them informed and involved in decisions about their care and treatment. The service was responsive to the individual needs of the children and young people who used it. The service was planned and delivered to meet the needs of the children and young people who lived locally.

Medical and nursing staffing were both found to be significantly under establishment and the risk register showed the service had identified medical and nursing staffing as a risk in April 2012. There was a high usage of medical locum staff and nursing staff were regularly moved between wards, units and sites in order to try and ensure the needs of the children and young people using the service were met. Nurse staffing levels on the children’s ward did not meet current national guidelines; staffing levels on the SCBU complied with current requirements.

The service did not have all of the necessary risk assessments in place for assessing children and young people prior to their admission and stay. For example, we found there were no nutritional risk assessments and no moving and handling risk assessments.

However, the management team were committed and feedback from staff was generally positive. There were systems and processes in place to assess and monitor the quality of service children and young people received. Risk management systems were in place.

End of life care


Updated 23 October 2015

We saw that end of life care services were safe, caring, responsive and well led. However, we saw that improvements were required in order for services to be effective. Mental capacity assessments were not being carried out on patients who were considered to be lacking capacity to be involved in discussions about DNACPR decisions. The trust needed to have a more systematic approach to recording mental capacity assessments in relation to DNACPR decisions where patients were unable to be involved in these discussions.

We observed specialist nurses and medical staff providing specialist support in a timely way that was aimed at developing the skills of non-specialist staff and ensuring the quality of end of life care. Specialist palliative care nurses provided a five day face to face assessment service which was different to the seven day face to face service available at Doncaster. While staff told us the Doncaster on-call nurse could see patients in Bassetlaw if required, this was not widely known by staff at Bassetlaw. There was an agreement by the trust’s corporate investment committee to recruit to a further two end of life care nurses to provide an improved service for patients at Bassetlaw District General Hospital. We were told that staff were caring and compassionate and we saw the service was responsive to patients’ needs. There were prompt referral responses from the specialist palliative care team and a good focus on preferred place of care and fast track discharge for patients at the end of life wishing to be at home.

Action had been taken against the issues identified in audits including the National Care of the Dying Audit. The implementation of the last days of life individual plan of care (IPOC) had been closely monitored by the end of life care coordinator with continuous reviews and feedback in place to develop this. A business case had been developed to increase the capacity of the end of life care/specialist palliative care service and the trust board had committed investment in improving the service as a result. The trust had a clear vision and strategy for end of life care services and participated in regional discussions and collaboration in relation to strategic planning and delivery of services to improve end of life care in the region.