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Doncaster Royal Infirmary Requires improvement

We are carrying out checks at Doncaster Royal Infirmary 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

Doncaster Royal Infirmary 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.

Doncaster Royal Infirmary 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 800 beds. The hospital also provided emergency and urgent care and outpatients and diagnostic imaging.

We inspected Doncaster Royal Infirmary as part of the comprehensive inspection of Doncaster and Bassetlaw NHS Foundation Trust. We inspected the hospital on 14 – 17 and 29 April 2015.

Overall, we rated Doncaster Royal Infirmary as requires improvement. We rated it good for being caring and well-led and requires improvement for responsive, effective and safe.

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.
  • Clostridium difficile (C. difficile) rates for the trust (44 cases) were within trajectory (45 cases) for the Trust for 2014/15.
  • 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.
  • The Summary Hospital-level Mortality Indicator (SHMI) (01-Jul-13 to 30-Jun-14) showed no evidence of risk. The Hospital Standardised Mortality Ratio indicator (01-Jul-13 to 30-Jun-14) showed an elevated risk.
  • Records indicated compliance with mandatory training and appraisal rates were generally low across the services. It was unclear in some areas if this was a recording issue; in any event, the trust were not assured that staff had received necessary training.
  • Within diagnostic imaging, there were some doors with no signage that had unrestricted entry to x-ray controlled areas.

We saw areas of outstanding practice including:

  • The Integrated Discharge Team was a beacon of good practice, as recognised by the 2015 National Award for Collaborative Leadership and was very active in providing a discharge planning service to all adult in-patients. The Frailty Assessment Unit was another example of effective collaborative working; the service enabled rapid assessment of elderly patients and person-centred care planning.
  • Selected Serious Incidents were rerun in the Clinical Skills department with the team originally involved in the incident to identify learning points.
  • 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 arrangements for the initial assessment of patients, including the use of streaming and triage, and add streaming / triage to the risk register
  • The trust must ensure appropriate numbers of medical, nursing and support staff of the required skill mix are available in the emergency department
  • The trust must ensure patient waiting times are reduced to ensure the 95% target for patients seen within four hours is met and maintained
  • The trust must ensure patients’ pain symptoms are assessed, and pain relief administered promptly for all groups of patients.
  • 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, emergency department and critical care unit that facilitates the prevention and control of infection.

In addition the trust should:

  • The hospital should review how the privacy and dignity of patients is maintained, particularly in the central (overflow) area of the emergency department
  • The hospital should review equipment in the emergency department to check appropriate and adequately serviced, working equipment is available.
  • The hospital should take steps to support and develop working arrangements between the emergency department and other specialities within the trust
  • The hospital should review arrangements for sharing with staff lessons learned from root cause analysis and investigation of incidents
  • The hospital should consider reviewing its audit programme for evidenced based guidance to include the review of adherence to clinical guidance
  • The hospital should record and monitor daily temperatures of fridges used for storage of medicines
  • The hospital should review and complete actions identified in CQC’s review of health services for children looked after and safeguarding, September 2014

  • The trust should review the need for diabetes management to be included in the mandatory training programme for trained nurses.
  • Medical services management should seek assurance that deprivation of liberty is being appropriately assessed and an order sought where required.
  • The trust should review access to an emergency buzzer system on M1, M2 and G5.
  • The trust should review the midwife to birth ratio.
  • The trust should review the rates of induction of labour and non-elective caesareans.
  • The trust should consider employing a specialist diabetes midwife.
  • The trust should review the management of medicines on the maternity unit, particularly the area the home birth trolley/ drugs are kept.
  • The trust should consider having a designated bereavement area in maternity.
  • The trust should review the domestic abuse policy to ensure it is consistent with NICE guidelines
  • The trust should continue to manage patient flow to reduce the number of outliers in surgery and gynaecology.
  • The trust should review the need for a standardised way of ensuring cleaning has taken place (environment and equipment).
  • The trust should ensure that it has effective assessments and plans in place for any evacuation of the critical care unit.
  • The trust should take action to improve the provision of storage facilities across the critical care unit.
  • The trust should improve the standards of infection prevention practice on the critical care unit.
  • The trust should as part of its overall patient pathway management ensure that patients on the critical care unit are discharged in a timely fashion to a more suitable environment.
  • The trust should consider in its overall development strategy a more suitable location for its critical care unit.
  • The trust should review segregation of children from adults in the recovery areas of the theatres.
  • 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 review the system for recording mental capacity assessments for patient’s unable to be involved in discussions about DNACPR decision
  • The trust should support staff involved in receiving bodies into the mortuary with adequate training to carry out the role
  • 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 to monitor the effectiveness of services within outpatients and diagnostic imaging.
  • The trust should review actions to improve safety and privacy within the medical imaging department particularly for inpatients who attend the department on beds.
  • 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

We rated outpatients and diagnostic and imaging as requires improvement. Safe and well-led required improvement; effective was inspected but not rated and caring and responsive were good.

There is a legal requirement to protect the public from unnecessary radiation exposure. We saw that there were 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. Not all areas had been addressed when we revisited as part of an unannounced inspection 10 days later. 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. Imaging and nursing staff reported that a safety handover of the patients from the wards did not occur. Inpatients were left waiting in beds on the main corridor of the department with no escort. This practice potentially created safety risks.

Records showed the number of staff that had received mandatory training and an annual appraisal was below the trust compliance target of 85%, particularly in outpatients. We saw patient personal information and medical records were mostly managed safely and securely. However there was limited evidence of audit to demonstrate effectiveness. This included IR(ME)R related audits. Radiation Exposure/ DRLs were not audited regularly. Patient’s records were not routinely audited.

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. Most referral to treatment targets were met including all cancer related targets. There was no centrally held list of all patients requiring a review or follow-up appointment. Medical imaging was not meeting the 6 week target referral to treatment target; however improvements had been made.

Staff we spoke with were aware of the trust overall vision and strategy and were positive about the recent and future management of medical imaging and outpatients. An outpatient’s services strategy had been drafted 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 require improvement.

Midwifery and nursing staffing levels at Doncaster Royal Infirmary did not always meet the ratio recommended (Safer Childbirth RCOG 2007). The interim head of midwifery met with the director of nursing on a monthly basis to discuss staffing levels and plans for ensuring the service had appropriate capacity and capability to meet the needs of women. The hospital had a safe staffing escalation policy which included a process to be followed in the event of sudden staffing shortfalls.

The maternity unit closed eight times between July 2013 and December 2014. In March 2015, the EPAU was closed for five days due to staffing problems.

Medical staffing was in line with national recommendations for the number of births. However, there were two consultant and two middle grade vacancies. Medical staff told us this could impact on their workload.

Participation in mandatory training was between 0% and 100%. It was variable across all the wards, clinics and departments. Training attendance for infection prevention and control was very poor, as it was for resuscitation, fire safety and information governance. Participation in safeguarding adults and children training was variable in the unit and was between 75%- 100%.

There was a multidisciplinary approach to the care and needs of women. We observed examples of considerate and compassionate approaches in the care and treatment of women. Feedback from women about the standard of care they received was positive. Women were treated with kindness, dignity and respect during their care and treatment.

The individual needs of women were taken into account when planning the support needed during their pregnancy, although there were a high proportion of induced births and non-elective caesarean sections. The number of home births was lower than the England average.

On the whole, maternity ward areas were visibly clean and equipment was in date and in working order. Medicines were managed appropriately.

The gynaecology services were negatively impacted upon by the number of patients outlying on the ward from other specialties.

Arrangements were in place to safeguard women and children from abuse, but some staff were not fully aware of the procedures around domestic abuse. Serious incidents were monitored and action taken when things went wrong. There was an open and transparent culture that encouraged reporting and learning from adverse incidents

The maternity and gynaecology services were led by a committed team. Consultants told us that midwifery management of the service was very good. The hospital has recently been awarded the highest level of the UNICEF Baby Friendly Initiative.

Medical care (including older people’s care)


Updated 23 October 2015

There were trust-wide systems in place to ensure that a root cause analysis was undertaken for serious incidents including a Serious Incident Panel and selected Serious Incidents were rerun in the Clinical Skills department with the team originally involved in the incident to identify learning points. Clostridium difficile (C. difficile) rates for the trust (44 cases) were within trajectory (45 cases) for the Trust for 2014/15. The wards were generally well equipped. All medical nurses were expected to be trained in Immediate Life Support skills and most units had achieved over 60% training rates; however three wards had training levels at 43-45%.

There was a trust-wide quality metrics audit framework for ward managers to complete (Ward Quality Assessment Tool). Audits were undertaken to monitor compliance with guidance, such as hand hygiene audits. Results seen showed good levels of compliance. The Trust responded to the outcome of the Sentinel Stroke National Audit Programme (SSNAP) for 2013/14 and the National Diabetes Inpatient Audit (2013) by taking action to improve the quality of service and care provided.

In the last staff survey, 63% of Trust-wide staff said they had received an appraisal in the last year although the current systems recorded 42%.

Seven day services were widespread with seven day consultant cover, 24 hour seven day pathology services and numerous allied health professional and specialist teams also providing seven day services.

Patients generally provided very positive feedback about the care provided by nursing staff. Patient buzzers were answered promptly in most areas visited. Many patients were positive about the staff ensuring that they understood the plan of care. Some patients were aware of their care plan and treatment objectives and felt fully involved but others were less clear in their understanding and wanted more information. Patients and family members said that medical and nursing staff were approachable and responsive if they did raise concerns. Staff were described as attentive, eager to help and asking if they needed anything on a regular basis. Several said how the staff made sure that they understood what was planned and provided reassurance when needed.

The trust was seeking to improve mortality and morbidity (national comparative data) performance through seven day working and this was reflected in the improved provision of seven day consultant cover for general medicine and specialist services including the Integrated Discharge Team, therapists and the diabetes specialist team. Discharge arrangements were managed by a multidisciplinary integrated discharge team. Medical outliers were managed through a trust-wide escalation process using a RAG rating on the whiteboards in order to reduce inappropriate transfers within the hospital.

Each care group involved in providing medical services had a documented operational plan for 2015-17 which identified current risks, anticipated pressures to the service and planned actions to mitigate the risks. Consultant vacancies and bed pressures were being experienced across medical services; however there had been a focus on medical workforce planning by care group managers and there had been a good response to the most areas of medical recruitment.

Staff were generally positive about the leadership and the levels of engagement with their line management through to executive level. The culture of the organisation was one of open communication and this was confirmed by many of the staff we spoke to.

Urgent and emergency services (A&E)

Requires improvement

Updated 23 October 2015

There were concerns as to the triaging or initial clinical assessment of patients which were not on the risk register. During streaming staff were unable to administer pain relief. At night there was no dedicated triage or streaming nurse: staff within the department undertook this according to demand. There were insufficient numbers of nursing staff for the safe operation of the service. The department were facing significant challenges in recruiting emergency medical staff.

There was insufficient working equipment available for staff to use. During the previous 12 months the trust had not consistently maintained the 95% target for patients seen within four hours. The standard of cleanliness and adherence to hygiene procedures was variable. Mandatory training was not up to date although an action plan had been prepared to improve the level of training compliance. The department used national guidelines; audits undertaken demonstrated a mix of good and poor results.

The emergency department had implemented an electronic patient record system widely used in the NHS and systems were in place to safeguard vulnerable adults and children. Some actions identified from the CQC review of health services for children looked after and safeguarding in September 2014 were still in progress.

Patients were cared for with empathy and with respect to their dignity. Privacy and dignity of patients was difficult to maintain because the limited environmental facilities did not support patient privacy. Most patients and relatives felt involved in their care and treatment. Staff demonstrated a good level of rapport in their interactions with patients and relatives. Staff provided emotional support to patients and their relatives.

The recently opened clinical decision unit provided excellent facilities for patients. Medicines were appropriately prescribed and administered. Controlled drugs were stored and stock recorded appropriately. There had been no recent never events and root cause analysis investigation of incidents was undertaken, although lessons learned were not shared consistently. Staff were aware of their responsibilities under the duty of candour requirements.

Patients received adequate nutrition and hydration. Staff could access clearly displayed information for each patient and patients were requested for their consent. Staff had received training in the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DOLs). Arrangements for staff appraisals were in place. A clinical education team provided the lead for staff training arrangements which supported staff working within their competencies. The outcomes of complaints were analysed to identify themes and trends.

The trust’s plans for the department involved significant reorganisation and the joint vision for the care group was shared by staff in the department. Working relationships between nursing and medical staff were good but there was limited interchange with some specialities. There were good working relationships with physiotherapists and occupational therapists.

The administration of pain relief was identified as a concern and pain management in the department had been included in the risk register. Governance arrangements had recently been reviewed to reflect changed departmental structures. Recent changes in leadership arrangements had presented some challenges which had been escalated and senior staff spoke positively about the new leadership team. There was an open culture in the emergency department.



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.

Intensive/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.

Services for children & young people


Updated 23 October 2015

We rated effective, caring, responsive and well-led as good. Safe was rated as required 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 meet the needs of the children and young people using the service. Nurse staffing levels on the children’s wards did not meet current national guidelines.

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. There were systems in place to manage risk.

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.