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Doncaster Royal Infirmary Good

Inspection Summary

Overall summary & rating


Updated 19 February 2020

Inspection areas


Requires improvement

Updated 19 February 2020



Updated 19 February 2020



Updated 19 February 2020



Updated 19 February 2020



Updated 19 February 2020

Checks on specific services

Medical care (including older people’s care)


Updated 10 July 2018

Our rating of this service stayed the same. We rated it as good because:

  • We rated safe, effective, caring, responsive and well- led as good.
  • Staff were aware of how and when to report incidents including safeguarding concerns. We saw that staff received feedback and lessons learned were shared.
  • All areas we visited were clean and well- maintained. Staff practiced safe infection control techniques and we saw predominantly positive audit results.
  • Staff assessed patients for risk of deterioration and escalated their care when necessary.
  • We saw safe medical and nurse staffing levels in place.
  • We saw good examples of multidisciplinary working. The trust performed better than the England average in a number of national audits.
  • Staff told us they were encouraged and supported to professionally develop.
  • We saw staff seeking patient consent before providing care and treatment. We saw that capacity assessments were completed for some, but not all, patients.
  • Patients, relatives and carers we spoke with gave consistently positive feedback: patients told us they felt safe on the wards and that staff were caring and compassionate.
  • Patients and their relatives told us that they were involved in planning their care and that communication with staff was good.
  • Staff were emotionally supportive to patients and their loved ones. Friends and family test responses were predominantly positive.
  • Services were planned to meet the needs of local people. Consultants were available seven days per week.
  • Care and treatment for vulnerable patients, such as those living with dementia or a learning disability, were seen as a priority. We saw numerous positive examples of initiatives in place for these patients.
  • There was a clear leadership structure. Staff told us that their line managers were visible, approachable and supportive. We saw positive leadership at ward and team level.
  • Staff were aware of the trust’s vision and values, Local governance arrangements were robust. Ward managers attended care group governance meetings. Ward managers were aware of the risks to their service.
  • We saw numerous examples of improvements and innovation.


  • There was low compliance in some mandatory training modules for medical staff.
  • There was a high percentage of nurse bank and agency use on some wards and not all patients were seen by a consultant within 14 hours of being admitted to the hospital in line with national guidance.
  • The service did not ensure VTE assessments were routinely reviewed within 24 hours in line with NICE guidelines.
  • We found that some patient pathways were out-of-date for review and did not have any references to nationally recognised, evidence-based, best-practice guidance.
  • The trusts performance was worse than the England average for the national heart failure audit and the national lung cancer audit.
  • Appraisal rates had improved since our inspection in 2015, however they remained lower than the trust target on some wards.
  • Consent to care and treatment was not always obtained in line with legislation for patients who lacked capacity.
  • The trust reported high numbers of delayed discharges and was not monitoring patient bed moves at night.

Services for children & young people


Updated 10 July 2018

Our ratings of this service stayed the same. We rated it as good because:

  • We rated effective, caring, responsive and well led as good. Safe was rated as requires improvement.
  • Sepsis screening tools were used and all the records of patients we saw with suspected sepsis were managed appropriately.
  • Care and treatment was based on national guidance and the service monitored the effectiveness of care and treatment.
  • Staff cared for patients with kindness and compassion, ensuring they involved patients and their families. Feedback we received about the services from patients and their families was positive.
  • The service was responsive to the needs of the individual children and young people who used it.
  • Children’s services were actively involved with the Integrated Care System (ICS) to plan care to reflect the needs of the local population.
  • There were effective governance systems and processes in place. Regular review of the risk register took place.


  • Safeguarding training rates were below the trust target.
  • There were no individual risk assessment tools to ensure the effective management of children and young people with mental health needs. Not all staff had received training in caring for children and adolescents with mental health conditions, but this had started to be addressed.
  • Actual staffing levels did not meet planned levels and the nurse to patient ratio exceeded the Royal College of Nursing (RCN) guidance (2013).
  • We observed that staff were not always using personal protective equipment or following appropriate hand hygiene practices.
  • There were environment issues, such as out of order shower cubicles on the children’s unit, water damaged ceiling tiles and protruding wires on the neonatal unit and condemned televisions were being stored in the adolescent room on the children’s ward.
  • We observed medicines left unattended.

Critical care


Updated 23 October 2015

Overall critical care services at Doncaster Royal Infirmary were judged as good.

There were 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 overall, though as a relatively new care group unit further focus was required on the development of the unit in terms of space and facilities.

The service met the individual needs of patients whilst they were on the unit. Early discharges and out-of-hours discharges were similar to other units, and out of hours discharges to the ward were slightly above that of other similar units. There were some concerns regarding patients being discharged from the critical care unit delayed by over four hours.

Within safety, concerns were identified with regard to the environment and the risks associated with evacuation in the event of a fire and distance from other services that were required for the effective functioning of the unit. The poor use of storage and the impact this had on infection prevention risks and the practices for nursing patients with infections.

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. Hotel services staff were not adequately trained or supported in the receipt of bodies to the mortuary and we were not assured by the trust’s arrangements for the storage of bodies in the mortuary in a way that respected the dignity of patient’s after death. 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 seven day face to face assessment service. 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. The development of an electronic referral/alert system had seen an increase in referrals to the end of life care team in a timely manner. A business case had been developed as a result and the trust board had committed investment in expanding the end of life 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.



Updated 23 October 2015

Incidents were reported and effectively investigated, and lessons were learned. The wards and departments were mostly clean and well maintained. However, there were worn floors and dust and dirt on trolleys and autoclaves in the theatre sterile supply unit. We found medicines and records were managed appropriately. The service responded appropriately to clinical risk in patients, although not all staff had received safeguarding training. There were some shortages of nursing and surgical staff; the trust were aware of this and were actively recruiting to fill the vacancies.

We found evidence-based care and treatment which was audited in the wards and departments. There was a system for the provision of pain relief to patients although it had been identified there were delays in the provision of analgesia to patients referred to the surgical assessment ward by their GPs. We found effective systems for the provision of nutrition and hydration to patients. Patient outcomes data did not show the trust to be an outlier in any area of practice.

Mandatory training records showed compliance with the 85% target for achievement of this was poor. However, the majority of staff we spoke with told us they were up-to-date with their mandatory training. There were systems in place for yearly appraisal. We found that the surgery services were caring and that patients received compassionate care. We found evidence of service planning and delivery to meet the needs of local people.

The percentage of patients waiting to start treatment (incomplete pathway) within 18 weeks from point of referral to treatment was better than the national target, however the number of patients who had to wait longer than 18 weeks from referral to treatment (admitted) breached the operational standard.

We found that the trust had systems in place that assisted in meeting the needs of people who used the service.

The surgical care groups at Doncaster were well-led with a vision and strategy for the service and systems of governance, risk management and quality measurement in place.

Urgent and emergency services


Updated 19 February 2020

Our rating of this service improved. We rated it as good because:

  • Since the previous CQC inspection, nurse staffing levels had improved and two paediatric nurses provided nursing cover for at least 95% of the time. A member of paediatric medical staff was allocated to paediatric emergencies 24 hours a day seven days a week.
  • The domains of safe, effective, responsive and well-led had each improved one rating since the previous inspection.
  • Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.
  • Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with national standards. Staff completed risk assessments for each patient swiftly and acted upon patients at risk of deterioration.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs and kept them informed. Staff provided emotional support to patients, families and carers to minimise their distress.
  • For paediatric patients, play leaders visited the department daily and also worked with patients under 16 years assigned to child and adolescent mental health services to support their emotional wellbeing.
  • Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. Staff gave patients enough food and drink to meet their needs and made adjustments for patients’ religious, cultural and other needs
  • A revised patient flow arrangement had been implemented and the hospital had commenced detailed planning for a phased upgrade of the emergency department to improve the experience of patients.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development. Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide effective care.
  • It was easy for patients to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included patients in the investigation of their complaint.
  • Staff attitudes were changing and staff morale had improved from the previous inspection. Medical and nursing staff worked well together.
  • Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services and collaborated with partner organisations to help improve services for patients.
  • Staff were committed to continually learning and improving services. They had a clear understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research.
  • Key services were available seven days a week to support timely patient care. On-site access to mental health services was 24 hours a day. The mental health team based within the emergency department had strengthened relationships with mental health services


  • The service provided mandatory training in key skills including the highest level of life support training to all staff but compliance with some training was low and did not meet the trust standard, particularly for medical staff.

•When the emergency department was crowded there was significant delay in assessing and treating children and adults with potential for serious harm to patients and the environment was not appropriate for maintaining the patient’s privacy, dignity and confidentiality.

•Pathways and particularly the system for referral to surgery needed improvement.

•In the week of our visit 81.7% of patients attending the Doncaster Royal Infirmary emergency department were seen with four hours. The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department.

•The mental health assessment room was located adjacent to the paediatric waiting area. Although the location of the room was identified as a high risk in the department’s risk register this did not include how the risk was being mitigated.

•The level of safeguarding training completed did not meet the recommendations of the intercollegiate guidance for level three. Although compliance with training standards had improved for nursing staff, for medical staff compliance remained low.

•The management of medicines requiring refrigeration did not provide assurance these medicines were safe to use.

•Extra consultant cover was needed in all areas of the department and the department had insufficient middle grade doctors to provide consistent support for consultants. Staffing of the minor injuries unit often fell below the planned level.

•Staff understanding of the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005 was limited. Staff were not clear about the process of assessing capacity.

•Some medical staff were not fully conversant with the concept of risk management or with how it applied to the risk register for the emergency department.

Diagnostic imaging

Requires improvement

Updated 19 February 2020

We previously inspected diagnostic imaging jointly with outpatients, so we cannot compare our new ratings directly with previous ratings.

We rated it as requires improvement because:

•There had been a lack of senior leadership in post as the due to long term sick leave and staff vacancy, there had been no head of service post since March 2019. In relation to this, a number of outstanding actions had not been fulfilled, such as recruitment of a permanent radiation protection supervisor (RPS) and delivery of actions from the previous CQC inspection. A new head of service had now been recruited and they were due to commence their role in October 2019.

•Senior managers and directors had collated all the outstanding actions into a plan for the new head of service to accomplish, however very little progress had been made on the issues identified during the previous inspection.

•The service did not provide evidence that radiation protection supervisors (RPS) had completed appropriate training or had been formally appointed. Local rules had been recently updated but were not available in every scan room and had not been signed by all staff.

•The service did not have an effective equipment quality assurance programme in all areas. For example, we did not see evidence of patient data collection to review doses for plain film or mobile x-ray and ultrasound checks were inconsistent.

•At department level, staff told us that, although managers were supportive, they needed to be more visible by coming on to the department and talking to staff rather than spending large amounts of time in their offices.

•The service had ongoing challenges with staffing levels across all disciplines within the department. This had been identified on the departmental risk register with risks rated as extreme for breast screening administrative staff to high risk for radiographers, abdominal aortic aneurysm screening, mammographers and interventional radiographers. Some of the staffing risks had been on the departmental risk register since January 2017, categorised as high risk, with no recent updates on progress of reducing or minimising risk.

•Overall mandatory training compliance for allied health professionals, medical and nursing staff was 69.5% against a trust target of 90%. For medical staff, the 90% target was met for only five of the 11 mandatory training modules for which medical staff were eligible.

•Medical staff had not kept up to date with safeguarding training specific for their role; for example, only 53.3% of medical staff had completed safeguarding adults and children level 2 compared with the trust’s completion rate of 90%.

•Staff recognised and reported incidents and near misses. However, there was limited evidence of lessons learned from incidents being shared with staff across the wider service.

•From April 2018 to March 2019, 71.3% of required staff in diagnostic imaging had received an appraisal compared to the trust target of 90% although the trust had recently reviewed its process and all appraisals were now undertaken between April and June each year.

•At our previous inspection, we had concerns about a lack of diagnostic reference levels (DRLs) audits. At this inspection, we found that the service had conducted some audits of doses against DRLs across the trust. This showed that five rooms across the service, including the x-ray room at Retford hospital was producing higher doses, due to older computed tomography (CR) equipment. However, we saw no evidence that these rooms had been subject to proactive optimisation or more frequent testing to mitigate this.


•Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

•Staff clearly described how they would report incidents using an online tool. Feedback from incident reporting was via email or staff meetings. Staff told us they talked openly about incidents and operated a no blame culture. Staff understood the duty of candour and what needed to be done when things went wrong.

•Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Staff provided emotional support to patients to minimise their distress. Staff involved patients and those close to them in decisions about their care and treatment.

•It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included patients in the investigation of their complaint. Most patients we spoke with told us that they had been told how to raise a complaint or they would know how to raise a complaint.


Requires improvement

Updated 19 February 2020

Our rating of this service stayed the same. We rated it as requires improvement because:

•The service did not make sure all staff completed mandatory and safeguarding training in key skills. The numbers of staff who completed it did not meet trust targets and managers had not appraised all staff’s work performance during 2018/19 to provide support and development.

•Staff we spoke with did not demonstrate a good understanding of mental capacity, best interest and deprivation of liberty.

•The service did not have enough midwifery staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The highest staffing vacancies were in the community midwifery, the central delivery suite and M1 the post-natal ward.

•The one to one ratio (95%) for women in labour had not been achieved. The 13 June 2019 maternity workforce report confirmed that 84% of women received one to one care at Doncaster Royal Infirmary.

•Current community midwifery caseloads did not reflect the current ratio of 98 cases per whole time equivalent midwife. (National Institute for Health and Care Excellence guidance) The caseload information for midwifes who worked 37.5 hours weekly ranged from 66 to 166 women per caseload.

•Monitoring of surgical safety checklists was not in place.

  • Although, the trust confirmed that monitoring of neonatal early warning scores and women’s maternity early obstetric warning scores was in place we were unable to ascertain whether scores were being escalated appropriately and whether patient outcomes had improved through this monitoring process.

•Shortfalls in monitoring, calibration and servicing of some equipment was found.

•A scavenger system was not in place to ensure the removal of entonox (nitrous oxide) gases from birthing rooms. Atmospheric checks were not in place to monitor levels of entonox gases. Following the inspection, the trust confirmed that testing for nitrous oxide in the maternity birthing rooms on both hospital sites had been completed and the results awaited.

•Gaps were observed in authorisation processes of the supporting documentation for patient group directions.


•Staff treated women with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff supported and involved women in their care and treatment decisions.

•Leaders understood and had started to manage the priorities and issues the service faced. In 2018/19 the trust completed an organisational restructure which encompassed most of the acute provider services to four ‘Divisions’ from six ‘Care Groups’. Obstetrics was in the children's and families division. A new management structure was put in place and a new head of midwifery appointed following the retirement of their successor.

•The service had enough medical staff with the right qualifications, skills and experience to keep women and babies safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix and gave locum staff a full induction.

•Mitigation strategies were in place in respect of midwifery staffing shortfalls.

  • Following inspection, the maternity service confirmed that the whole service had a budgeted establishment to meet 1:28. At the time of inspection vacancies existed and the trust had offered 20 whole time equivalent new midwives positions and were waiting for them to commence employment on the 21st October 2019 once their NMC PIN Numbers had been received. The additional midwives would improve the ratio of births to midwives from 1:32 to 1:27.4 in line with RCM recommendations.

•The service provided care and treatment based on national guidance and evidence of its effectiveness. Joint policies, guidelines and procedures were in use across the service.

•The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care.



Updated 19 February 2020

We previously inspected outpatients jointly with diagnostic imaging, so we cannot compare our new ratings directly with previous ratings.

We rated this service as good because:

  • The service provided mandatory training to all staff. Equipment and the premises were visibly clean. Staff managed clinical waste well. There were enough staff to keep patients safe and provide the right care and treatment.
  • Staff kept records of patients’ care and treatment. Records were up to date and easily available to staff providing care. The service administered, recorded and stored medicines safely.
  • Staff recognised incidents and reported them appropriately. Managers shared lessons learned locally with the team,
  • The service based care and treatment on national guidance and individual specialities managed NICE guidance compliance rates within departments. Medical staff prescribed and administered pain relief for minor procedures.
  • Staff worked together as a team to benefit patients and provide good care and were competent for their roles. All staff had completed their appraisal. Staff knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
  • The service provided outpatient clinics between 9am and 5pm, Monday to Friday. Some clinics were provided in the evenings or weekends to meet demand. People could access food and drink. The service had relevant information promoting healthy lifestyles and support.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff provided emotional support to patients, families and carers to minimise their distress. Staff supported patients, families and carers to understand their condition.
  • The service planned and provided care to meet the needs of local people. The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services.
  • People could access the service when they needed it. Although some specialties struggled to meet demand, most waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with national standards. Staff treated concerns seriously, investigated them and managers shared lessons learned with staff.
  • Local managers were visible and approachable for patients and staff. They supported staff across the department. The service and senior leaders had a vision for what it wanted to achieve and a strategy to turn it into action.
  • Staff felt respected, supported and valued, and focused on the needs of patients. The service provided opportunities for career development with an open culture where staff could raise concerns without fear.
  • Although the ‘did not attend’ rate was higher than the England average at all of the trust’s sites, a new text reminder and respond system had been implemented. Managers and booking centre staff told us the trust had been able to reduce the rate significantly over two full months prior to our inspection.
  • Leaders operated effective governance processes. Managers worked with partner organisations. Staff at all levels were clear about their roles.
  • Leaders managed performance effectively. Environmental risks were identified and recorded.
  • The service collected data to understand performance, make decisions and improvements. The information systems were integrated and secure.
  • Leaders and staff engaged with patients, staff, and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.
  • Leaders encouraged innovation and participation in research.


  • Some outpatients staff did not follow trust policy regarding security of paper prescriptions.
  • There was not always an indication on equipment that it had been cleaned and cleaning checklists were not always completed.
  • Records were not always clear, and staff did not always adhere to professional record keeping standards.
  • Learning from never events was not shared widely across different outpatient departments at the trust.
  • The trust did not display information for patients on how to make a complaint.
  • There was a waiting list for review patients in ophthalmology and an incident had occurred where a patient had not received the right care promptly. Patient review appointments were managed centrally by the trust bookings team and managers said their processes were robust and would not allow a backlog of review appointments. However, the incident investigation had identified over 700 patients in ophthalmology had no review appointments. Following the inspection, staff told us the trust, with the CCG, had commissioned an external review of all waiting lists. They told us all ophthalmology patients on the review list had their appointments brought forward.
  • Information provided by the trust prior to our inspection showed no clinics were cancelled. However, they later provided information to show 20% of all outpatient clinics were cancelled.
  • Although the trust told us there was a system in place to identify and record patients waiting for long periods within clinics, we did not see this being followed in practice in all outpatient areas during our inspection. There were some long waiting times within clinics and not all departments informed patients on arrival how long they would need to wait or the reason for any delay.
  • Some staff were unaware who executive leaders were.
  • Although staff were aware of departmental plans relevant to their own area, not all staff were aware of how they linked in with the overarching trust strategy.
  • Risk registers did not include all risks and reviews of actions taken were not documented.
  • Senior leadership operated at directorate level and outpatients departments and specialties worked separately from each other. It was not clear if leaders had an overview of the outpatients department as a whole.