Bassetlaw District General Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

At our last assessment in 2017 we identified that staff had not received training around mental health condition and on this assessment, we saw this had improved.

We have not awarded this service a score for Safe.

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

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There was a daily departmental safety huddle during which leaders reviewed staffing allocation, capacity and patient flow, safeguarding concerns, and any other issues that could impact the safe delivery of services. Leaders advised that compliance with these huddles was monitored monthly to ensure they had taken place, with assurance and outcomes reported by the Matron to divisional meetings.

Some staff could identify which incidents to report and how to report them. Staff told us they felt safe to raise concerns with their managers.

Leaders told us that staff were good at reporting all incidents via the electronic safety system. Staff described how they received feedback from investigations of incidents through a number of pathways, including through the incident reporting system, governance meetings, emails, meetings with the manager, patient safety boards and ‘lightening learning’.

Leaders facilitated regular mortality and morbidity meetings and shared findings from audit activity, including the paediatric sepsis audit. Reviews of complex cases, including a paediatric death, demonstrated reflective practice. Discussions considered the clinical, ethical and emotional aspects of care, including the importance of advance care planning and effective communication between specialist and local services.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

Staff knew what to do when a patient was deteriorating and the criteria when children and young people needed a higher level of clinical care. There was a clear Standing Operating Procedure (SOP) to support this.

Leaders told us that a STOPP (Safe Transfer of the Paediatric Patient) tool was used to ensure safe transfer of children and young people. There was access to transport to transfer parents, children and young people across site where needed.

A transition strategy (2026–2030) was in place to support young people moving from children to adult services. This included clear objectives and a dedicated transition team, which supported continuity of care for children with long-term conditions.

Medical support was available 24 hours a day, with clear escalation routes to the consultant on call. Structured communication tools, such as Situation, Background, Assessment, and Recommendation (SBAR), were used to support safe handover between staff. Consultant-led handovers took place twice daily, with appropriate nursing input.

Senior nursing support was available 24 hours a day through band 6 and band 7 staff, with additional support from a band 8a matron during daytime hours. The adult site team provided out-of-hours support. Staff told us that their immediate leadership team were visible and responsive. At the time of our assessment, recruitment was underway to provide additional support to both the assessment unit and the emergency department.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying,

Staff and leaders told us they knew how to support children at risk of, or experiencing, significant harm. They knew how to make a safeguarding referral and who to inform if they had concerns. Staff were aware of external agencies and knew how to refer to the Multi Agency Safeguarding Hub (MASH), and they would check on Child protection Information Sharing (CPIS) records to identify if there were any safeguarding concerns.

Staff had received safeguarding supervision, and this was recorded.

Staff had completed safeguarding children’s and adults training; they were below the trust target however this only equated to a single member of staff who had not completed their training. The unit manager had an overview of training and staff were reminded to complete their training.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Parents, children and young people we spoke with said staff gave them a full explanation of their treatment, including the risks. Patients said staff explained care and treatment in a way they could understand and they were provided written information to take home.

We observed parents, children and young people being given a full explanation of their treatment in a way in which they could understand.

Staff had completed CAHMS training and there was mental health champion who provided ongoing support and professional development to staff.

The service detected and controlled potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care.

The environment was newly refurbished and was decorated in a child friendly way.

The department was clearly signposted. Both outpatients and the assessment unit entrances were locked, and access was via a buzzer or intercom which enabled staff to prevent any unauthorised access.

We observed that areas were clean and well maintained with no clutter in the corridors.

There were isolation rooms and a mental health assessment room available which was ligature free.

Staff completed a daily ‘Safe to Care’ checklist to monitor the clinical environment. The checklist included checks of fire exits, refrigerator temperatures, oxygen supplies, medicines management, and resuscitation equipment. Outcomes from the checklist, along with any required actions, were communicated to staff to support ongoing safety and compliance.

Equipment had been serviced and was in good working order. Staff had received training in the equipment they were using.

Electronical equipment had all been portable appliance tested and consumables were in date. All fluids hazardous to health which were in Control of Substances Hazardous the Health (COSHH) guidelines were locked away. We observed that fire exits were clear and signposted and there was a well-equipped, secure outdoor play area.

The service did not always make sure there were enough qualified, skilled and experienced staff. Leaders did not always make sure staff received effective support, supervision and development. Staff did not always work together well to provide safe care that met people’s individual needs.

Nurse staffing currently had a 99% fill rate. However, staff told us they did not feel there were enough staff on the assessment unit, when it was busy. Staff were required to support the emergency department when a very sick child or young person attended.

The senior team told us that a staffing review was being undertaken using the safe nursing care tool (SNCT) staffing tool. The department were in the process of recruiting to a supernumerary co-ordinator role. There were staffing huddles 3 times a day to identify where further staffing support was required. There was cross site working in place to support teams.

The department had completed a self-assessment against the Royal College of Paediatrics and Child Health (RCPCH) Facing the Future standards, which set out the requirements for delivering safe and effective paediatric services, including standards for consultant and middle-grade medical staffing, access to senior clinical decision-makers, and service availability.

At the time of our assessment, the department was not fully compliant with the standards due to medical staffing shortfalls. Leaders had developed an action plan and implemented a recruitment programme to address these gaps and support future compliance with the standards.

A consultant was available on the ward throughout the day and evening and on call overnight. The senior resident doctors were available out of hours. Resident doctors said they received good supervision from consultants.

The outpatient unit was staffed by two clinical team members and did not have a dedicated receptionist. Staff told us that during busy periods, particularly when both clinicians were engaged in clinic rooms, there was no designated person available to greet patients or visitors, which could affect the accessibility and efficiency of the service.

New staff were provided with a three-week supernumerary induction period, supported by a comprehensive internal training programme that included both e-learning and face-to-face training.

During our assessment we noted that play specialists were available on the ward Monday to Friday to support children’s wellbeing and engagement through age-appropriate activities.

A comprehensive training needs analysis was in place, and staff demonstrated a clear understanding of their mandatory and role-specific training requirements. Effective reminder and reporting systems were in place, and senior leaders maintained clear oversight of training compliance and completion rates. While not all staff had completed Paediatric Advanced Life Support (PALS) training, this related to only three members of the nursing team. The department mitigated any associated risk through appropriate skill mix arrangements and workforce rostering.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We observed the area was clean, tidy and free from clutter. The required furniture was in place and well maintained. All equipment was visibly clean and carried in date ‘I am clean’ stickers.

Staff described the daily cleaning processes and checks. We reviewed the ‘Daily Safety Check Checking check list.’ This included equipment and hand sanitisers.

We observed staff either washing their hands or using hand sanitiser appropriately. All staff were bare below the elbows during patient contact.

Handwash was available at entrances and sinks.

Toilets and hygiene areas displayed posters reminding staff of hand hygiene procedures.

The service used an electronic audit system to monitor infection control. Results were shared at the divisional governance meeting with matron’s oversight.

Staff were able to describe the process to follow if sepsis was suspected. There had been significant work on raising awareness about this, across the department.

A dedicated infection control nurse audited the department, with results demonstrating a good level of compliance with action plans in place, where needed.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

There were systems in place to reduce the risk of medicines-related harm.

Staff followed clear processes for checking prescriptions, including verification of dose, route, allergies and potential interactions. Weight-based dosing was used for paediatric patients, and two trained staff checked high-risk medicines.

Patient identification checks were undertaken prior to medicines administration.

Staff took steps to reduce dispensing errors. They used separate baskets and QR codes to track who prepared medicines. The service was moving to electronic prescribing. Staff expected this to reduce errors, when copying prescriptions.

The pharmacy team lead described how they would challenge any prescriptions that were incorrect or unclear to ensure patient safety. Medicines reconciliation processes were in place at admission, transfer and discharge.

Staff demonstrated effective antimicrobial stewardship. Audit data showed appropriate cultures were taken prior to treatment, antibiotics prescribed in line with guidance, and significant improvement in documentation of review or stop dates.

Medicines were stored safely and securely. The trust had an up-to-date medicines management policy. Pharmacists provided support to staff, via an on-call system.

Leaders used audit to monitor compliance with medicines management standards. Recent audit results showed good compliance levels, with identified issues relating to fridge temperature monitoring and escalation, which were addressed and shared for learning.

We reviewed medicine related incidents for the last 12 months. Appropriate action had been taken in response, including application of duty of candour and shared learning.