Bassetlaw District General Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people’s outcomes were consistently good, which feedback confirmed.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Parents, children and young people told us they were involved in decisions about their individual needs. They said staff listened to them and ensured they fully understood the information provided.

We observed a ward round and saw that the teams worked together to review care and explain this to children and young people, parents and their families.

We also observed outpatient’s clinics and saw staff explaining care and treatment in a way people could understand.

Staff completed a full assessment of children and young people on admission and risks were documented. However, documentation audits were currently paused and being reintroduced in June 2026, in a new electronic format.

The service assessed and responded to the individual needs of children and young people, including those with special educational needs and disabilities (SEND). SEND resources, such as sensory boxes and communication aids, were available across the service to support engagement and understanding. A SEND lead oversaw quality improvement work in this area, working in partnership with families, plans were in place to establish a dedicated SEND working group.

Children and young people were further supported by a youth worker and hospital school team, which contributed to a holistic approach to care.

A paediatric pain policy was in place, although this was due for review. Staff used appropriate pain assessment tools, and records confirmed ongoing monitoring and review of pain. There was a pain audit in place, and this had identified that there was a downward trend in pain scoring documentation, and the timeliness of pain relief given. There was an action plan in place which included improving communication tools and having a pain awareness month initiative to raise this topic with staff.

The department used nationally recognising tools for assessing needs such as Paediatric Advanced Warning Score. They planned to move to the Paediatric Early Warning Scores (PEWS), once this was added to the electronic patient record.

Staff actively participated in clinical audit and quality improvement activity to support evidence-based care. Ward accreditation audits were completed annually, and the service had addressed all actions identified in the previous audit. The Children’s Assessment Unit had achieved 94% at the last audit.

Matrons and ward mangers undertook weekly and monthly audits to monitor the service. Findings from these audits were reported on the care and excellence quality dashboard and discussed at leadership meetings. Actions were clearly identified and tracked.

Most clinical guidelines were up to date and supported evidence-based practice. A multidisciplinary paediatric guideline group was responsible for reviewing and approving guidelines. Of 141 guidelines, 10 were identified as overdue or requiring review. This meant the service could not provide assurance that clinical guidance was consistently reviewed and maintained in line with best practice.

Compliance with National Institute for Health and Care Excellence (NICE) guidance was reported as 96%, demonstrating a high level of adherence to nationally recognised evidence-based standards designed to improve patient outcomes, safety and the quality of care provided.

Staff used a range of evidence-based tools to support clinical decision-making, including those for pain assessment, recognition of the deteriorating child, and sepsis management. The use of these tools could support staff to identify changes in a child’s condition promptly, assess and manage risks consistently, and ensure care was delivered in line with recognised best practice, supporting improved patient safety and outcomes.

The service worked well across teams and services to support people. Staff made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff wore colour-coded uniforms to support the easy identification of different staff groups. This was complemented by posters and patient information materials explaining staff roles and responsibilities. These resources had been introduced in response to feedback from children, families and carers, which could improve their understanding of the multidisciplinary team and enhance their experience of care.

Staff rotated between Bassetlaw General Hospital and Doncaster Royal Infirmary outpatients. Leaders told us that this ensured a consistent way of working and prevented staff from feeling isolated.

Staff told they worked well as a multidisciplinary team. We saw specialist nurses and community teams on the unit. Staff told us they had access to the safeguarding team for advice. Community teams delivered outpatients clinics, and we saw them working well with staff.

The team worked closely with the SEND service to support children with additional needs. Staff shared patient information effectively during handovers, promoting continuity of care between shifts. We observed a comprehensive handover process, and staff demonstrated a clear understanding of the priorities for the shift.

Teams worked collaboratively across departments and with partner services, including discharge teams, consultants, specialist services, and the Child and Adolescent Mental Health Services (CAMHS) team, to support coordinated and holistic care that met the needs of patients and their families.

Diagnostic and pharmacy services were available seven days a week, supporting timely access to investigations, medicines, and treatment.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

We observed a wide range of patient information leaflets, booklets, and posters containing QR codes to enable downloading of information to electronic devices.

There was a range of information at the end of each bed/cot which was easily accessible to parents and carers.

The service had established evidence-based pathways for long-term conditions, including childhood obesity and type 2 diabetes. These pathways included clear referral routes to community services, enabling children and families to access ongoing education, lifestyle support and multidisciplinary input beyond the acute setting.

The service routinely monitored people’s care and treatment to continuously improve it. Staff ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The service had an established audit and quality improvement programme. A forward plan included 36 projects for 2025/26. While this demonstrated a structured approach to quality improvement, 8 had been deferred, which limited assurance that all planned improvements had progressed within expected timescales.

The service participated in national audits, to benchmark performance. Results from the National Children and Young People Asthma Audit showed performance above the England average across all five indicators.

Participation in the Epilepsy12 audit demonstrated improvement aligned with the National Epilepsy Bundle of Care, with quality improvement priorities identified for future development.

Local audit processes identified areas requiring improvement. For example, fluid balance audits identified poor compliance in recording and total calculations. A revised fluid balance chart was developed and further refined following testing. However, audit findings from intravenous fluid therapy reviews indicated ongoing gaps in documentation, which meant improvements were still being embedded into practice.

Outcomes and performance were monitored through monthly review meetings, which included patient experience feedback. Feedback from children, young people and families was captured through surveys and the friends and family test, with generally positive results.

Ward-level audit data, demonstrated high compliance in most areas, providing assurance of good quality care.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Parents, children and young people received clear and helpful verbal and written information before consenting to their procedures.

Gillick competency requirements are clearly set out in the hospital Consent to Examination or Treatment Policy. Staff told us how they gained consent from children and young people before undertaking and care and treatment.

Staff were able to describe how they would support children with mental health needs.

However, the service did not undertake consent audits. While the service recognised this gap and had plans to introduce consent audits, the absence of formal monitoring meant the service could not fully assure that consent processes were consistently applied and documented in line with policy.