Bassetlaw District General Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This meant the service was consistently managed and well-led. Leaders recognised aspects of the culture required improvement and as such had taken action to improve it. Leaders mitigated risks to ensure that person-centred care was received by all children and young people using the service.

At our last assessment we rated this as good and at this assessment it has remained good.

We have not awarded this service a score for Well-led.

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

The evidence showed some shortfalls. The service had adopted trust vision and values. The service did not have a children’s and young people’s strategy but planned to develop one. Work was ongoing to improve the culture amongst staff groups within the service. Staff did not always understand the challenges and the needs of people and their communities.

Cultural and behavioural concerns had previously been identified within paediatric services across Doncaster Royal Infirmary and Bassetlaw Hospital. These concerns had been escalated appropriately and prompted a comprehensive internal review. This resulted in an action plan with five strategic priorities focused on improving culture, leadership and patient safety.

An external ‘A Kinder Life’ cultural review had been commissioned to further explore behaviours and staff experience within the service. Early engagement had taken place with consultant staff.

The trust had a clear organisational vision: “Healthier Together – Delivering Exceptional Care for All "

The trust had core values which were the WE CARE values, We always put the patient first, Everyone counts – we treat each other with courtesy, honesty, respect and dignity, Committed to quality and continuously improving patient experience, Always caring and compassionate, Responsible and accountable for our actions – taking pride in our work, and Encouraging and valuing our diverse staff and rewarding ability and innovation

The DBTH Way was supported by core values of being kind, inclusive, person-centred, empowering, accountable and collaborative, supported by behaviours including attentive listening, integrity, honesty, courage and positivity. We saw evidence that these values were being applied within children’s services, particularly in relation to work addressing health inequalities and improving patient experience.

Staff were aware of the Trust’s overall strategy, vision and values; however, the service did not have a dedicated children and young people’s strategy. Plans were in place to develop this, including a three-stage engagement programme involving children and young people. However, the absence of a current strategy limited assurance of a clear, service-specific vision and direction.

Early progress towards developing this strategy included the recruitment of a youth worker and the introduction of a youth group to gather feedback and lived experience. The longer-term ambition was to develop a Children and Young People Charter by 2027 to guide future priorities and service development. The service’s current quality priorities were aligned with wider trust objectives.

Leaders had identified the further development of Developmentally Appropriate Healthcare (DAH) as a key priority for 2026. DAH is a recognised approach to delivering care that is responsive to the developmental needs of children and young people, supporting age-appropriate communication, engagement in decision-making, and preparation for transition to adult services. The planned work could enhance the overall experience and outcomes for young people using the service.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Patients could feedback their views through the friends and family survey.

Leaders described the training and development they had received. This helped them undertake managerial duties and provide specialist input for patients. Some staff told us that they had not been able to access development opportunities due to limited funding availability and this was reflected in staff survey.

Leaders clearly explained how teams worked to provide high quality care. They provided examples of audits, learning from trust wide safety events and quality improvement.

Staff told us ward managers and matrons were visible and approachable.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff and leaders were aware of the freedom to speak up (FTSU) process, and how to contact the freedom to speak up lead. There had been two concerns raised and both had been acted on by the service. The ward accreditation framework identified that not all staff felt comfortable in speaking up, or that their concerns would be heard. Not all staff had received training for FTSU awareness.

Nursing staff had access to a Professional Nurse Advocate whose role was to deliver clinical supervision, support with incidents, enhance staff wellbeing, resilience, and retention.

The trust had systems in place to support a culture where staff could raise concerns. Regular Freedom to Speak Up (FTSU) reports were presented to the board, with the most recent detailed update provided in March 2026. This report demonstrated oversight of progress against previously identified actions and supported the development of the trust’s ‘Speaking Up Strategic Plan’ (2026–2028).

Actions had been taken to strengthen the FTSU function, including improvements to leadership support and learning processes. Staff could access the trust’s Speaking Up policy and were supported through tools such as the ‘Being Fair’ framework following patient safety incidents.

Overall, while systems to support speaking up were established and functioning, further work was required to strengthen local engagement and provide assurance that all staff felt confident and supported to raise concerns.

The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff participated in the staff survey and there was a departmental action plan in place. Staff told us they worked well as a team and enjoyed working there. They were proud of the environment and how they had helped to develop the service.

The trust had an equality, diversity and inclusion (EDI) improvement plan in place, which outlined a wide range of actions to improve workforce equality. Progress had been made against the actions aligned to the Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES). Ongoing work was evident across most of the trust’s five high-impact priorities. However, this information was not clearly broken down at service level, which limited assurance of how improvements specifically impacted children’s services.

The trust demonstrated a commitment to promoting an inclusive culture. It had achieved ‘Bronze status’ in recognition of its anti-racism work, with executive leadership supporting this agenda. Initiatives such as corporate induction events, which included content on allyship and anti-racism, supported staff awareness and engagement.

Staff completion of equality, diversity and human rights training was high, although there was some variation across staff groups.

The trust promoted an inclusive culture through a range of initiatives, including staff recognition events, awareness campaigns and support for international staff.

Staff were supported through flexible working arrangements and reasonable adjustments to meet individual needs. Managers demonstrated an understanding of their responsibilities in supporting staff wellbeing and inclusion. Local initiatives, such as the paediatric ‘Star’ nomination programme, encouraged staff recognition and positive team culture.

The service had clear responsibilities, roles, systems of accountability and good governance. Staff used these to manage and deliver good quality, sustainable care, treatment and support. Staff act on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The service had a well-established governance structure for the management of risk, quality and performance. Dedicated medical and nursing governance leads were in place for the department and provided representation within the wider divisional governance framework.

All staff participated in a daily safety huddle that followed a structured format. This provided an opportunity to share updates on incidents, discuss learning, and communicate any actions required to support the safe delivery of care. Monthly team meetings were also held to facilitate communication and engagement across the service. Staff told us that formal minutes were not routinely taken for these meetings; however, key discussions, decisions and actions were documented where necessary to ensure appropriate records were maintained.

Staff locked all computers when not in use; therefore, patient-identifiable information remained inaccessible. However, on one unit, we observed staff leaving paper records unsecured and accessible within a ward area. We escalated this to the ward manager who immediately secured the records.

Leaders told us they had access to information to support them with their management role. There was an inhouse leadership programme they were able to access. This included information on service performance, staffing and patient care.

The department use the Patient Safety Incident Response Framework (PSIRF) to review incidents. The outcomes of any incident investigation were shared at the safety huddle, staff meeting and the weekly staff huddle.

The clinical governance teams had lightening learning in place to communicate outcomes of incidents and actions.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. Staff shared information and learning with partners and collaborated for improvement.

The teams worked well together. Community staff carried out clinics within the children’s outpatient’s clinic area which allowed staff access to them for advice. We spoke to staff who were visiting the service including a health visitor and specialist nurse, they told us that their felt part of the team. Additional members of the multidisciplinary team were invited to the ward round where appropriate.

Community groups supported the department through donating play items for the children whilst inpatients.

The team actively sought feedback from local communities to improve the patient experience including through their Little Voices initiative.

The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. They actively contribute to safe, effective practice and research.

The service demonstrated a commitment to continuous learning and improvement through a range of quality improvement initiatives. These included the introduction of specialist roles, such as transition nurses, sepsis nurses, practice development nurses, audit nurses and a mental health champion. Additional roles, including youth workers, site practitioners and professional nurse advocates, supported service development and staff wellbeing.

The mental health champion had made significant progress on staff training in mental health and developing a safe space on the unit for the assessment of children and young people with mental health needs.

The team constantly looked for ways to improve the patient experience, they had Little Steps Big Voices which had enabled them to explore the service from a user’s perspective, and they had made improvements to signage and to the environment, such as footsteps on the floor to guide people to areas.

The service had undertaken work on health inequalities and were integrating this into business planning to ensure that future developments reflected the needs of the local population.

Governance arrangements had been strengthened through the implementation of the Patient Safety Incident Response Framework (PSIRF), the introduction of patient safety panels, and joint governance meetings between paediatric and emergency department teams across all hospital sites. These changes supported a more coordinated and learning-focused approach to patient safety.

The service responded to national safety learning and patient feedback. The introduction of Martha’s Rule ‘wellness questions’ enabled families to escalate concerns and supported early identification of deterioration.